Pain Management Coding Alert

Question: Is there any way to report prolonged evaluation and management (E/M) services with emergency department (ED) E/M codes?

Montana 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 the evaluation and management of a patient including admission 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.

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