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.
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

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

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

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