HIV, STIs and Viral Hepatitis Routine Screening Emergency Department Toolkit: Testing and diagnosis

A lack of a clear protocol for testing, compounded by an overwhelming demand for care, causes staff roles to blur and leaves the bulk of the workflow on the clinician’s shoulders, including obtaining consent, disclosing results, counseling, and coordinating follow-up care.

Defining a routine testing plan streamlined by EHR support, outlining a clear post-test protocol, and clarifying team member roles can help incorporate routine screening more seamlessly into standard workflows.

Some clinicians and staff may also feel intimidated by interpreting results and next steps for the inconclusive test results. For HIV, clinicians are often unaware what the next step is upon a positive diagnosis. Providing education on the latest evidence-based guidance for screening, testing and treatment can instill confidence in the care team and provide a more personal approach to address the patient’s needs.  

• Screening guideline ambiguity and the need for clarity for all test result scenarios and who to notify and when to notify them 
• Knowing they have the responsibility to check results and make follow-up calls, clinicians are hesitant to screen in addition to urgent clinical duties
• Education on interpreting results and next steps for inconclusive/indeterminate results
• Lack of on-site equipment and reliance on external labs thus clinicians are hesitant to order initial test if the patient will need to be referred out to a clinic and pay twice for testing
• Desire from patients to know results right away is at odds with testing logistics and can lead to loss of contact with the patient before results are complete 
• Pressure to meet other funder-driven requirements in addition to patient’s chief reason for visit 
• Knowledge and awareness of the appropriate CPT codes
• Lack of payer coverage for routine screening for HCV
• STD tests sometimes run into insurance denials based on diagnostic codes

1. Streamline the testing cascade 

   1. Optimizing the clinical workflow can help to streamline testing, clarify roles and ensure emergency department staff know what happens at each step along the way. Also, leveraging testing innovations like rapid antibody test technology or Reflex RNA for HCV, which allows for faster detection through the ability to immediately run another lab test on the same blood draw so that patients do not have to return for additional testing, allows for quicker delivery of results to patients. Clear guidance on testing interpretation and result sharing, in accordance with applicable privacy laws, will help reduce the cognitive load for health care professionals who are juggling a positive diagnosis with other immediate clinical needs. Strong relationships with local health departments (in particular, disease surveillance units) can also enable clinical staff members to rapidly identify which patients are experiencing a diagnosis for the first time, or who need reengagement in medical care.

   2. Related resources

   • Clinical algorithm flowcharts for screening: This set of documents translates screening guidance and clinical considerations from the USPSTF and CDC into a decision tree format to help outline steps in the testing continuum from beginning to end.
     • Clinical algorithm flowchart for HIV screening (PDF)
     • Clinical algorithm flowchart for Chlamydia and Gonorrhea screening (PDF)
     • Clinical algorithm flowchart for Syphilis screening (PDF)
     • Clinical algorithm flowchart for HBV screening (PDF)
     • Clinical algorithm flowchart for HCV screening (PDF)
   • Streamlined testing cascade: This set of infographics outlines the testing cascade for infectious diseases covered in this toolkit, including opportunities to optimize, and can be used as a tool to help clarify care team member roles at each step as well as define a clear post-test protocol.
     • Streamlined testing cascade for HIV in Emergency Departments (PDF)
     • Streamlined testing cascade for STI testing in Emergency Departments (PDF)
     • Streamlined testing cascade for HCV in Emergency Departments (PDF)
   • Screening guidelines form the CDC and USPSTF:
     • CDC Guidelines and Recommendations: Find information on guidelines and recommendations for delivering HIV, viral hepatitis, STD, and TB care.
     • USPSTF A&B Recommendations: This page outlines all of the USPSTF recommendations with a grade of either A or B including screening for HIV, chlamydia and gonorrhea, syphilis, hepatitis B, hepatitis C and latent tuberculosis infection.
   • Health Department directories: This resource from the CDC outlines who is working to protect the public’s health in your area, including senior health officials, state, local, and territorial health departments, and tribes and Indian organizations. Clinical staff may need to develop relationships with staff in various sections of health departments in order to facilitate reporting, linkage to care or prevention, and other critical services.

2. Outline funding and reimbursement strategies

   1. Breaking down direct and indirect costs for each element of routine screening and testing, across the health setting’s payer mix, will help identify gaps in funding and reimbursement and uncover opportunities for negotiation. Budgeting EHR development, equipment, the cost of tests, and staff time for routine screenings will eliminate unknowns and inspire confidence. Additionally, ensuring you are coding services properly for eligible patients will ensure you are reimbursed for the cost of the service and that the patient will not have any out-of-pocket costs.

   2. Related resources

   • Routine screening coding quick guide: This coding guide outlines a list of procedural codes related to HIV, STI and viral hepatitis screening for both private payer insurance and Medicare and helps you ensure that you are coding services correctly for eligible patient populations to cover the cost of the service, with the patient having no cost-sharing responsibility.
     • Routine screening Medicare coding quick guide (PDF)
     • Routine Screening Toolkit: Private payer coding guide (PDF)
   • Potential resources to cover direct and indirect costs: The following links are listings of available funding opportunities that could help to cover screening related initiatives and associated costs at your clinic.
     • CDC’s National Prevention Information Network – Funding Opportunities
     • CDC HIV Funding and Budget resource
     • Rural Health Information Hub – HIV and AIDS Funding Opportunities
     • Grant funding through your state and local health department

Disclaimer: This page contains resources supplied by third party organizations. Inclusion of these materials on this page does not imply endorsement of these resources or corresponding organization.

The toolkit is organized across the screening continuum and offers helpful resources and best practices for the emergency department care team.

Step 1: Patient triage

Step 2: Initiating standard screening protocols

Step 3: Testing and diagnosis

Step 4: Education and post-test counseling

Step 5: Linkage to care

Resource library