Throw out these two rules, but apply the one that really matters.
You may think you know E/M coding rules, but when you’re coding in an emergency department (ED) setting, you’d better be prepared to leave a bunch of them at the door. That’s because issues of time and patient status, for example, don’t really apply in an ED setting, as the answers to the first two questions in this FAQ will show.
But there’s one major E/M component that doesn’t change no matter where the encounter occurs. Can you guess what it might be? Read the last answer and see if you’re right.
Q: Can you code for prolonged E/M services in the ED?
A: “You cannot use prolonged services codes with the ED E/Ms. However, the ED doctors can admit the patient to observation status and continue observing the patient until the decision to discharge or admit,” explains Joshua Tepperberg, CPC, senior coding analyst at Caduceus Inc., in Jersey City, NJ.
Takeaway: 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 on encounter specifics:
Melanie Witt, RN, CPC, MA, an independent coding expert based out of Guadalupita, N.M. had this to add about prolonged services coding in the ED:
“Prolonged services [codes] require an E/M service that includes a typical time and that must be billed before the prolonged services can be added on. Also, that prolonged service must exceed the typical time in the E/M code by 30 minutes before it can be added,” she says.
Don’t look for ED E/M times: 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.
So, you should make sure you never append these prolonged services codes to ED E/M codes 99281-99285:
Q: What’s the difference between a new and established patient in the ED?
A: The ED E/M codes do not differentiate between new or established, initial or subsequent. Each ED visit stands on its own with the supporting documentation.
“Even if you are well-known to the ED, you are still considered a new patient every time you present,” Tepperberg explains. “Since the ED is going to treat the urgent/emergent condition and may or may not have access to prior records — past history, current conditions, etc. — they will do a full workup and treat every condition like new to rule out any emergent complications or conditions that may be present.”
Q: What part of ED E/M coding is often forgotten by non-ED physician coders?
A: “My best advice on coding E/M levels in the ED is to take notice of your overall medical decision-making [MDM] first,” advises Tepperberg. “Once you are sure of your MDM, go back and ensure that the history and physical exam documentation is there to support the MDM. That, plus having an open channel of communication between the coder and provider, is essential to help both understand what is truly going on with each case.”
