Orthopedic Coding Alert

Scouring the claim to see if ED E/M patient is new or established? Don’t bother.

Filing evaluation and management (E/M) codes for emergency department (ED) services can confuse even the savviest coder, since most practices don’t regularly perform ED E/Ms. There are times, however, when your provider will find herself in a situation where ED E/M rules supersede the standard office E/M rules.

Given the differences between office E/Ms and ED E/Ms, forgetting some basic differences between the two services is understandable. When you start throwing in patient status and prolonged services issues, ED coding gets even more complicated.

Check out this FAQ, in which a pair of experts address some tricky ED E/M questions.

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:

• 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...).

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 must be billed before the prolonged services can be added on, and that prolonged service must exceed the typical time in the E/M code by 30 minutes before it can be added,” she says.

Editor’s note: 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:

• +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)
• +99355 — ... each additional 30 minutes (List separately in addition to code for prolonged service)
• 99356 — Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient Evaluation and Management service)
• +99357 — ... each additional 30 minutes (List separately in addition to code for prolonged service)

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.”