Billing Prolonged Services with Direct Patient Contact
Four steps lead you to proper coding and revenue capture.
Many of us struggle to bill prolonged services. Here’s what you should know to be sure you aren’t leaving money on the table.
CPT® defines prolonged services as, “when a physician or other qualified healthcare professional provides prolonged care involving direct patient contact that is provided beyond the usual service in either the inpatient or outpatient setting.” Direct patient contact is face to face, and includes additional, non-face-to-face services during the same session; however, Medicare will only accept prolonged services for the face-to-face time involved.
First, let’s review some basic facts:
- Prolonged services with direct patient contact are reported using CPT® codes 99354-99357.
- Prolonged services are add-on codes; you must report them with their companion evaluation and management (E/M) code.
- Prolonged services are time-based codes; therefore, time must be documented. This time does not need to be continuous.
- The documentation should indicate why the visit went beyond the usual services.
- Prolonged services are only billed when the time involved exceeds the typical time of the E/M service by at least 30 minutes; therefore, services less than 30 minutes in total duration are not reported separately.
Billing for prolonged services can be a complex process, but I’ve narrowed it down to four steps.
Step 1: Determine if Services Were Beyond Usual E/M
An E/M visit may go beyond the usual service because:
- The patient is noncompliant with the chosen treatment options.
- The patient has difficulty understanding the provider because of mental handicaps, physical handicaps, or language barriers.
- The provider has to explain complex treatment options, such as major surgery.
- The provider has to explain essential lifestyle changes to the patient.
Step 2: Determine the Patient’s Location
There are four codes to choose from when billing for prolonged services with direct patient contact. They are based on whether the patient is in the office/outpatient setting, or if the patient is in an inpatient/observation setting.
Report prolonged services in the office or outpatient setting with:
+99354 Prolonged service 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 service)
Report 99354 in addition to E/M codes 99201-99215, 99241-99245, 99324-99337, 99341-99350.
+99355 each additional 30 minutes (List separately in addition to code for prolonged service)
Report 99355 in addition to 99354.
Report prolonged services in the inpatient or observation setting with:
+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)
Report 99356 in addition to E/M codes 99218-99220, 99221-99223, 99224-99226, 99231-99233, 99234-99236, 99251-99255, 99304-99310.
+99357 each additional 30 minutes (List separately in addition to code for prolonged service)
Report 99357 in addition to 99356.
Step 3: Factor in Time
Calculating the time spent is key to billing prolonged care. Refer to Table A and Table B to determine if the typical time of the visit, as well as the actual time spent, supports billing of prolonged care.
Example 1: A new patient with cerebral palsy comes into the office to see a neurologist. The neurologist performs a comprehensive history, comprehensive exam, and moderate medical decision-making. Based on these three key components, the E/M level is 99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity; however, due to the patient’s inability to communicate with the neurologist, the visit takes 80 minutes instead of the typical 45.
Find 99204 in Table A and look to the column Threshold Time to Bill 99354. To bill prolonged care, a total of 75 minutes must have been spent. In this example, the visit was 80 minutes; therefore, the time spent supports billing a prolonged service.
If you bill the E/M service based on time, you must bill the highest-level E/M before you can factor in the prolonged service.
Example 2: A gastroenterologist informs an established patient that a lesion, biopsied a few days prior, is malignant. The provider spends 90 minutes reviewing surgical and non-surgical options with the patient. The entire visit consists of counseling and coordination of care. To bill this service based on time, the gastroenterologist would report 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity.
Find 99215 in Table A and scroll to the Typical E/M Time column. The time given is 40 minutes. Because the total visit was 90 minutes, the remaining 50 minutes may be billed as prolonged care.
Step 4: Calculate Total Duration of Prolonged Services
As the fourth and final step, you need to know which prolonged code to bill and the number of units. Table C illustrates the correct reporting of prolonged physician services with direct patient contact in the office/outpatient setting.
Table C: Office/Outpatient Setting
|Total Duration of Prolonged Services||Code(s)|
|Less than 30 minutes||Not separately reported|
|30-74 minutes(30 minutes-1 hour 14 minutes)||99354 x 1|
|75-104 minutes(1 hour 15 minutes-1 hour 44 minutes)||99354 x 1 and 99355 x 1|
|105 minutes or more(1 hour 45 minutes or more)||99354 x 1 and 99355 x 2(or more for each additional 30 minutes)|
In Step 3, we determined that you could bill for prolonged services for neurology and gastroenterology patients by using a threshold chart.
If you look at Example 1 and subtract the typical time spent (99204 = 45 minutes) from the actual time spent (Total time = 80 minutes) you get 35 minutes of prolonged service time; therefore, according to the Table C, you may bill 99204 and 99354 x 1.
In Example 2, the total time of the visit spent with the patient was 90 minutes. Per Table C, you would bill this visit 99215 and 99354 x 1.
Remember: Time is a crucial piece to billing prolonged care. If time isn’t documented, you can’t bill these services.
Christy Jackson, CPC, CPC-I, CCVTC, is a coding educator at University Hospitals (UH) in Cleveland, Ohio. She has worked as a coder for 13 years, primarily educating new providers on the basics of E/M services and creating educational materials, such as webinars and articles, for providers and coders within the UH system. Jackson is a member of the Cleveland, Ohio, local chapter.