How do I code for extended evaluation and management services where counseling and coordination does not comprise a majority of the visit?
In this case the use of prolonged services codes would be appropriate. These codes involve direct patient contact that is beyond the typical time for an evaluation and management service, and can be reported in addition to the evaluation and management code. You must document the reason for the prolonged service in the patient record to account for the use of these codes. There are different sets of codes for inpatient and outpatient settings. Each set includes a code for the first hour of prolonged services and another code for each additional 30 minutes.
