ED Coding and Reimbursement Alert

Question: How should our ED physician receive reimbursement when patients are kept in the ED while they are waiting to be transferred to another facility? During this time, we continue to monitor patients. Should we report prolonged services codes for these cases?

Washington Subscriber

Answer: No, that would be incorrect. Prolonged services codes (+99354, Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g. prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient evaluation and management service] and +99355, each additional 30 minutes [list separately in addition to code for prolonged physician service]) are add-on codes and are not to be used with ED E/M codes. CPT stated that 99354 should be used with 99201-99215, 99241-99245 and 99301-99350. ED visit codes 99281-99285 are not included in this list.

CPT does not allow prolonged services codes with ED E/Ms because there is no time component to these codes. Without a time component, it is impossible to determine if the services are prolonged or that patient contact is beyond the usual service.

An alternative is for the ED physician to admit the patient to observation if significant monitoring is indicated (e.g., 99234, Observation or inpatient hospital care). The ED physician must clearly document the reasons observation care is needed, including diagnosis and patient status, to support medical necessity. And it must be clear that the physician was personally involved in the care and monitoring during the time frame documented. The time does not need to be continuous.

If the patient's condition is stable and physician involvement is not necessary, the time spent in the ED facility, as well as the use of equipment, will be covered in the facility bill.

Reader Questions and You Be the Coder were reviewed by John Turner, MD, FACEP, medical director for coding and documentation at TeamHealth, Inc. in Knoxville, Tenn.; and Tracie Christian, CPC, CCS-P, director of coding for ProCode in Dallas.