ED Coding and Reimbursement Alert

Latest CPT axes prolonged E/M modifier --but offers EDs no alternative strategy.

Starting Jan. 1, ED coders will have to adjust to a deleted modifier and note some code set renumberings.

In 2009, coders can no longer rely on modifier 21 (Prolonged evaluation and management services), which was left off the roster of 2009 modifiers, confirms Joan Gilhooly CPC, CHCC, president of Chicago's Medical Business Resources.

Before this development, ED coders could append modifier 21 to the highest-level E/M service within a given category to account for "extra" encounter time -- for example, 99285 (Emergency department visit for the evaluation and management of

a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high

complexity ...). According to CPT 2009's Appendix A, "Modifiers": "Modifier 21 has been deleted. To report prolonged physician services, see +99354-+99357."

Caveat: While this development is good news for many specialties, it won't make an ED coder's day. According to CPT 2009, you cannot report +99354-+99357 in the hospital setting. So without modifier 21, there is really no way for ED coders

to capture extra time associated with an E/M service.

Explanation: "Time is not a component of ED E/M services, so prolonged services don't apply to this code set. This is perhaps the only instance where not having -time- associated with our codes hurts us," relays Michael Granovsky, MD,

CPC, FACEP, president of MRSI, an ED billing company in Woburn, Mass.

Depending on the reason for the extended stay, you may be able to report a higher-level E/M based on the complexity and medical necessity of the case.

But if the ED physician provides a level-three ED E/M (99283, - an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity ...) that takes longer than usual, you

cannot capture the extra time for that service.

You should note some code regroupings in newborn care, as CPT 2009 renumbers the entire section. Starting Jan. 1, 2009, you will report newborn services 99431-99440 with new codes 99460-99465.

"Though some of the code descriptors are modified to add clarity or consistency in the language, the codes are basically renumbered [in CPT 2009] to put the codes together," reports Cindy Hughes, CPC, a coding and compliance specialist in

Leawood, Kan.-

ED coders should also note these changes to pediatric and newborn E/M codes:

- pediatric critical care transport is now 99466 and +99467

- all inpatient neonatal and pediatric critical care codes are in the 99468-99476 code set

- codes for initial and continuing pediatric intensive care services are in the 99477-99480 group.

It will be unusual for most ED physicians to report these codes since they describe a full day's service and are valued commensurately. They are available if the physician provides this type of service, however.

Keep in mind, states Granovsky, that the pediatric critical care transport codes specify a requirement for direct face-to-face patient care for children younger than 24 months of age.