Avoid Prolonged Services Pitfalls

Knowing which guidelines to follow ensures successful E/M reporting.

By G. John Verhovshek, MA, CPC

Before reporting prolonged service codes 99354-99357, consider that American Medical Association (AMA) and the Center for Medicare & Medicaid Services (CMS) coding requirements may differ.

Evaluation and Management – CEMC

For CPT® 2009, AMA revised the descriptors of inpatient critical care codes +99356 Prolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual service; first hour (list separately in addition to code for inpatient Evaluation and Management service) and +99357 Prolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual service;  each additional 30 minutes (List separately in addition to code for prolonged physician service) to eliminate the phrase “direct (face-to-face) patient contact” and replace it with “unit/floor time.”

For instance, physicians may bill unit/floor time for reviewing medical records, documenting, and discussing the case with other providers. The descriptor change brings consistency with other inpatient service codes (such as inpatient consults 99251-99255) that also measure unit/floor time, rather than face-to-face time.

Medicare, however, still requires direct face-to-face time for all inpatient prolonged services. Medlearn Matters number MM5972 (www.cms.hhs.gov/MLNMattersArticles/downloads/MM5972.pdf), effective July 1, 2008, specifies, “You cannot bill as prolonged services … In the hospital setting, time spent reviewing charts or discussing the patient with house medical staff and not with direct face-to-face contact with the patient or waiting for test results, for changes in the patient’s condition, for end of a therapy, or for use of facilities.”

This means, when reporting inpatient prolonged services codes 99356-99357 to Medicare or any payer that follows CMS guidelines, count only the time the provider spends in direct contact with the patient.

Outpatient Service Requirements Match

CMS and CPT® requirements for outpatient prolonged services both require you to count only time spent in direct contact with the patient. The descriptors for +99354 Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management service) and +99355 Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service; each additional 30 minutes (List separately in addition to code for prolonged physician service) specify “face-to-face.” As well, Medlearn Matters MM5972 stresses, “You may count only the duration of direct face-to-face contact with the patient.”

Document Time with Precision

“You must appropriately and sufficiently document in the medical record that [the provider] personally furnished the direct face-to-face time with the patient specified in the CPT® code definitions,” according to Medlearn Matters MM5972. For all payers (even those not requiring face-to-face time for inpatient services), document the start and end times of the visit, along with the date of service.

The time counted toward prolonged services need not be continuous, but must occur on the same date of service. CPT® specifies that prolonged service codes “should be used only once per date, even if the time spent by the physician is not continuous on that date.” For instance, the physician may consult with a patient in the hospital, spend 30 minutes discussing his condition, leave to perform regular rounds, and return later in the day to that patient for another 40 minutes of counseling. The time spent with the patient both before and after the physician made rounds can contribute toward prolonged services.

Finally, documentation must explain why the physician provided prolonged services. Medlearn Matters MM5972 states, “Documentation is required to be in the medical record about the duration and content of the medically necessary evaluation and management service and prolonged services that you bill.” For instance, simply noting the physician spent an extra 60 minutes with the patient is not adequate to support a claim. The medical record must show the medical necessity for the extra time spent.“Unless you have been selected for medical review, you do not need to send the medical record documentation with the bill for prolonged services.”

The message is clear: Payers may not want full documentation upon initial claims submission, but it had better be available on request.

Add-on Prolonged Services with Approved E/M Codes

You may report prolonged service add-on codes only in addition to E/M codes including a reference time. As such, you would report outpatient services 99354 and 99355 with:

99201-99215                  Office or other outpatient visit

99241-99245                  Office or other outpatient consultation

99324-99337                  Domiciliary, rest home, or custodial care services

99341-99350                  Home services

Similarly, you must apply 99356 and 99357 only in addition to:

99221-99223                  Initial hospital care

99231-99233                  Subsequent hospital care

99251-99255                  Inpatient consultation

99304-99310, 99318     Nursing facility services

Document at Least 30 Additional Minutes

To report an initial prolonged services code (99354 outpatient or 99356 inpatient), the physician must document at least an additional 30 minutes beyond the reference time of the chosen E/M service level, according to CPT® guidelines. CMS requirements also stress, “You should not separately report prolonged service of less than 30 minutes total duration on a given date, because the work involved is included in the total work of the evaluation & management (E/M) codes.”

You may use +99355 (outpatient) or +99357 (inpatient) to report each additional 30 minutes beyond the first hour of prolonged services, based on the place of service. These codes may be used to report the final 15-30 minutes of prolonged service on a given date, if not otherwise billed. “Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately,” according to Medlearn Matters MM5972.

See Charts A and B for a complete list of threshold times (that is, minimum total documented time for the service) for reporting prolonged services.

Generally, you will select an E/M service using the key components of history, exam, and medical decision making (MDM), using the prolonged services codes, as appropriate, to account for physician time over and above the reference time for that service.

For example, a physician performs an expanded problem-focused history, an expanded problem-focused exam, and MDM of low complexity for an established outpatient. By these criteria, the visit meets the requirements of:

99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family. The total visit time is 65 minutes, or 50 minutes greater than the reference time for 99213, so you may report 99213 with one unit of 99354.

When counseling and/or coordination of care comprise more than 50 percent of the total time with the patient, you may use time as the determining factor when selecting an E/M service level. In such a case, however, you may only report prolonged services with the highest code level in that code family as the companion code.

For example, a physician performs an office visit with an established patient. Of a total visit time of 75 minutes, 60 minutes was spent on face-to-face counseling and coordination of care with the patient. Based on time alone, the physician may report a level V established outpatient visit (99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family), which has a 40 minute reference time. Based on the additional 35 minutes over and above this reference time, the physician may also report a single unit of 99354.

Chart A: Threshold Time for Prolonged Visit Codes Billed With Office/Outpatient and Consultation Codes

Code

Typical Time for Code

Threshold
Time to Bill
Code 99354

Threshold Time to
Bill Codes
99354 and 99355

99201

10

40

85

99202

20

50

95

99203

30

60

105

99204

45

75

120

99205

60

90

135

99212

10

40

85

99213

15

45

90

99214

25

55

100

99215

40

70

115

99241

15

45

90

99242

30

60

105

99243

40

70

115

99244

60

90

135

99245

80

110

155

99324

20

50

95

99325

30

60

105

99326

45

75

120

99327

60

90

135

99328

75

105

150

99334

15

45

90

99335

25

55

100

99336

40

70

115

99337

60

90

135

99341

20

50

95

99342

30

60

105

99343

45

75

120

99344

60

90

135

99345

75

105

150

99347

15

45

90

99348

25

55

100

99349

40

70

115

99350

60

90

135

 

Chart B: Threshold Time for Prolonged Visit Codes 99356 and/or 99357 Billed with Inpatient Setting Codes

Code

Typical Time for Code

Threshold Time to Bill Code 99356

Threshold Time to Bill Codes 99356 and 99357

99221

30

60

105

99222

50

80

125

99223

70

100

145

99231

15

45

90

99232

25

55

100

99233

35

65

110

99251

20

50

95

99252

40

70

115

99253

55

85

130

99254

80

110

155

99255

110

140

185

99304

25

55

100

99305

35

65

110

99306

45

75

120

99307

10

40

85

99308

15

45

90

99309

25

55

100

99310

35

65

110

99318

30

60

105

 

G. John Verhovshek, MA, CPC, is AAPC’s director of clinical coding communications.

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One Response to “Avoid Prolonged Services Pitfalls”

  1. John Tyree ACNP says:

    I recently ran into an issue where I and a night cross cover saw a patient in back to back fashion across the span of a few days. The first practitioner to see the patient each calendar day billed 99233 and then when the cross cover was called back to the room later in the day for different issues they billed 99356. The times are documented in 2 of the 3 days, however the 99356 codes were rejected because the primary billing Icd-10 code was different visit to visit. I have not been able to find any CMS manual documetation or updates that state 99356 primary ICD-10 has to match the initial 9923x. do you have any idea where this may be comeing from.

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