The purpose of this study was to determine the levels of agreement between three methods of assessing appropriateness of emergency department (ED) visits. In particular, we tested the agreement between internists and emergency physicians reviewing the ED nurses' triage notes, containing information that might be available by telephone to an internist. For 892 adult patient ED visits reviewed, we found only moderate agreement (kappa = 0.47) between these groups. In cases of disagreement, emergency physicians were 10.3 times more likely than internists to classify those with minor discharge diagnoses as appropriate for ED care. As managed care grows, the determination of ED appropriateness may depend on open discussions between physician groups, as well as on access to timely care in office settings.