ED Coding and Reimbursement Alert

Question: A patient with a chronic gastric ulcer reports to the ED complaining of nausea, vomiting, and headache. One of our nonphysician practitioners (NPPs) spends 34 minutes with the patient, and performs an expanded problem focused history and exam and moderatecomplexity medical decision making during the encounter. During the history portion of the E/M, the patient reveals that she has not been to a physician in "four or five years" for treatment of her ulcer. The note indicates that the NPP spent 21 minutes advising the patient on proper diet and medication management, and encouraging the patient to resume regular physician visits for management of her condition. Is this an instance where I can code based on total encounter time?

New Jersey Subscriber

Answer: No; the ED E/M codes are not based on time, so you have to choose an E/M code based on level of service regardless of how much time the provider spends counseling the patient. On the claim, report the following codes:

• 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity ...) for the E/M

• 787.01 (Nausea with vomiting) appended to 99283 to represent the patient's nausea and vomiting

• 784.0 (Headache) appended to 99283 to represent the patient's headache

• 531.7 (Gastric ulcer; chronic without mention of hemorrhage or perforation) appended to 99283 to represent the patient's ulcer.

Explanation: You can only enact the counseling exception, thereby allowing you to code based on encounter time with time-based E/M codes such as 99201-99215 (Office or other outpatient visit for the evaluation and management ...).