ED Coding and Reimbursement Alert

Question: Can we report prolonged evaluation and management (E/M) services with emergency department (ED) E/Mcodes?

Codify Subscriber

Answer: No. You may not report prolonged services codes 99354 (Prolonged evaluation and management or psychotherapy service[s] [beyond the typical service time of the primary procedure] 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 or psychotherapy service]) through 99357 (Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; each additional 30 minutes [List separately in addition to code for prolonged service]) with emergency department (ED) evaluation and management (E/M) codes (99281-99285) as the ED E/M codes don't contain a time element.

However, if an ED E/M service becomes "prolonged," you might be able to code it as an observation visit instead, with the following codes, depending upon the encounter specifics:

• 99218 (Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity...) through 99220 (... a comprehensive history; a comprehensive examination; and medical decision making of high complexity...) or
• 99234 (Observation or inpatient hospital care, for theevaluation and management of a patient includingadmission and discharge on the same date, which requires these 3 key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity...) through 99236 (... a comprehensive history; a comprehensive examination; and medical decision making of high complexity...).

Bottom line: The 99281 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a problem » focused history; a problem focused examination; and straightforward medical decision making...) through 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity...) codes 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.