ED Coding and Reimbursement Alert

Tip: Read the fine print before assigning code 99354.

A frequent question among emergency department coders is how to capture ED visits that extended longer than the average visit. Although you may be tempted to report the prolonged service add-on codes, such as 99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management service]), those codes are not available for use with ED E/M codes. Follow our advice below to recoup all appropriate reimbursement for all your prolonged services encounters.

Get Up to Speed on The Changes

New language in CPT® for 2011 states, "Intraservice times are defined as face-to-face time for office and other outpatient visits and as unit/floor time for hospital and other inpatient visits. This distinction is necessary because most of the work of typical office visits takes place during the face-to-face time with the patient, while most of the work of typical hospital visits takes place during the time spent on the patient's floor or unit. When prolonged time occurs in either the office or the inpatient areas, the appropriate add-on code should be reported."

Note the absence of the emergency department in that last sentence. In the prolonged services code preamble, the instruction follows, "The use of the time based add-on codes requires that the primary evaluation and management service have a typical or specified time published in the CPT® codebook."

ED time tracking: The emergency department evaluation and management codes are unique in that time is not a listed component included in the code descriptor. This is because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time. That makes it difficult for physicians to provide accurate estimates of the time spent face-to-face with the patients in that setting.

With that exemption in mind, CPT® excludes codes 99281-99285 from the parenthetical list of codes that are available for use with prolonged service add on codes, which reads, (Use 99354 in conjunction with 99201- 992145, 99241-99245, 99324-99337, 99341-99350, 90809, 90815). Similarly, critical care codes 99291 and 99292 are not included since they are time-based codes themselves and would not require another add on code to capture the "prolonged service" work provided.

Consider Observation Codes Instead

Observation services might be an alternative code choice, provided your documentation supports these codes.

Reason: ED patients may require a prolonged stay because of the ongoing nature of their presentation and the medical necessity for serial reevaluations and modified treatment plans. In those circumstances, consider using observation service codes if the documentation supports an admission to observation status and ongoing assessments as to the best disposition of that patient.

For Example: An 18 year old with asthma presents with respiratory compromise to the extent that she has trouble speaking with moderate wheezing in all lung fields. She has been hospitalized previously for severe asthma attacks and a comprehensive history and physical exam are obtained. Labs are ordered and treatment begins including oxygen, bronchodilators, IV fluids, and IV steroids. There is only minor improvement after several hours and the patient is placed in observation status to continue treatment and determine the appropriate disposition. Repeat diagnostics and respiratory treatments show improvement and after ten hours, the patient is discharged home in stable condition.

With the appropriate documentation in place, this "prolonged" ED stay could be reported using an observation code such as 99235 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date which requires these 3 key components: a comprehensive history, comprehensive examination; and medical decision making of moderate complexity).