ED Coding and Reimbursement Alert

Hint: No need to stress about the ‘three-year rule.’

 It’s common for coders who are trained in outpatient coding to encounter a few stumbling blocks when they first enter the ED. After all, while some of the E/M coding conventions are the same across the board, many E/M rules are different in the ED than in other settings.

Check out this FAQ, in which a pair of experts address some tricky ED E/M questions. The answer can help guide coders who are new to the emergency department, and may even illuminate a few issues for ED coding veterans.

Q: Can you code for prolonged E/M services in the ED?

A:  “You cannot use prolonged services codes with the ED E/Ms. However, the ED doctors can admit the patient to observation status and continue observing the patient until the decision to discharge or admit,” explains

Joshua Tepperberg, CPC, senior coding analyst at caduceus Inc., inJersey City, NJ.

“Prolonged services [codes] require an E/M service that includes a typical time must be billed before the prolonged services can be added on, and that prolonged service must exceed the typical time in the E/M code by 30 minutes before it can be added,” says Melanie Witt, RN, CPC, MA, an independent coding expert based out of Guadalupita, N.M.

However, the 99281-99285 codes (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components...) have no time component, so there is no way to tell if an ED E/M service was prolonged beyond the typical level.

Without a time element within the ED E/M components, prolonged services are not applicable. In fact, the ED E/M codes are not included in the CPT^® parenthetical list of codes that may be reported along with +99354 (Prolonged evaluation and management…) for that very reason. However, as mentioned above, code +99356 (Prolonged service in the inpatient or observation setting…) does allow reporting with an observation code when appropriate.

So, you should make sure you never append the prolonged services codes to ED E/M codes 99281-99285.

Q: What’s the difference between a new and established patient in the ED?

A: The ED E/M codes do not differentiate between new or established, initial or subsequent. Each ED visit stands on its own with the supporting documentation.

“Even if you are well-known to the ED, you are still considered a new patient every time you present,” Tepperberg explains. “Since the ED is going to treat the urgent/emergent condition and may or may not » have access to prior records — past history, current conditions, etc. — they will do a full workup and treat every condition like new to rule out any emergent complications or conditions that may be present.”

Q: What part of ED E/M coding is often forgotten by non-ED physician coders?

A: “My best advice on coding E/M levels in the ED is to take notice of your overall medical decision-making [MDM] first,” advises Tepperberg. “Once you are sure of your MDM, go back and ensure that the history and physical exam documentation is there to support the MDM. That, plus having an open channel of communication between the coder and provider, is essential to help both understand what is truly going on with each case.”