ED Coding and Reimbursement Alert

Question: We do coding for an urgent care center within our facility and a question recently came up from the providers regarding patients who stay for “observation”. These providers are also work at one of our local hospital emergency departments and they asked about reporting observation codes in these cases. We have informed them that this would not be appropriate as we are not a hospital/facility setting. Would it be appropriate for them to report prolonged service codes in addition to the E/M code for these types of visits? If so, what type of documentation would they have to provider, i.e. just a statement for the total time of the visit, actual times the patient was seen by the doctor?

 Nebraska Subscriber

Answer: Observation is a status rather than a place of service; however, the title of the Observation section in CPT® is “Hospital Observation Services” so they should not be used in a non-facility setting. You can use the prolonged services codes with the office and other outpatient visit codes. These codes cannot be used with ED E/M services, which have no typical times assigned. You should document the time spent in excess of the typical time associated with the code. Something along the lines of a critical care attestation should suffice. Keep in mind the minimum time requirement in the table below. 

99354 (Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management service])