ED Coding and Reimbursement Alert

Question: We saw a patient in the ED with multiple problems, including diabetic neuropathy, high blood pressure, and the reason she presented, which was an ophthalmic migraine. In addition, we administered a pregnancy test which came out positive. The physician spent almost an hour with the patient and we’re wondering if we can use a prolonged service code along with 99285 for this visit.

Codify Subscriber

Answer: You cannot use prolonged services codes with the ED E/M codes, because the concept of time-based coding does not apply to this code set.

Prolonged services codes require an E/M service that includes a typical time, which 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.

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.

Of note, there is a code for prolonged services you could use with observation care: +99356 (Prolonged services in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour). You would need to document at least 30 minutes beyond the typical time listed for the base observation code in order to qualify for also reporting the add-on code.