Prolonged Services Updates and Other 2016 E/M Changes
Medically unlikely edits add restrictions to these codes.
The American Medical Association (AMA) focused on prolonged services for 2016 CPT®. New codes were created and guidelines have been updated. Take note, and apply the changes when reporting these evaluation and management (E/M) services.
Report Initial Prolonged Service Once, per Day
Although medically unlikely edits (MUEs) are commonly implemented by the Centers for Medicare & Medicaid Services (CMS), the AMA has started to implement them with prolonged services. Per CPT® instructions added for 2016, +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) and +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) may be reported only once, per date of service, even if the prolonged service is not continuous.
CPT® further instructs that prolonged services of less than 30 minutes are not reported separately, and are included in the work of the primary E/M service or psychotherapy code. Time for services other than the E/M or psychotherapy is not counted toward the time for prolonged services.
One Psychotherapy Code Is Allowed with Prolonged Services
The only psychotherapy service that may be billed with a prolonged service is CPT® 90837 Psychotherapy, 60 minutes with patient and/or family member. A minimum of 90 minutes must be documented for the encounter (e.g., 60 minutes of psychotherapy, plus at least 30 minutes of prolonged services). Prolonged services codes cannot be reported with CPT® +90838 Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure).
New Codes for Prolonged Services by Clinical Staff
Prolonged service may be provided by clinical staff when supervised by a physician or other qualified healthcare provider. The AMA created two new codes for this sort of encounter:
+99415 Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour (List separately in addition to code for outpatient Evaluation and Management service)
+99416 each additional 30 minutes (List separately in addition to code for prolonged service)
Report these services only with E/M codes 99201-99215.
Report 99415 in addition to the primary E/M service for the initial 45-74 minutes of prolonged clinical staff services (i.e., time in excess of that described by the primary E/M service reported). Per CPT® guidelines, report 99416 for each additional 30 minutes of prolonged clinical staff services beyond the initial 74 minutes, as follows:
Total Duration of Prolonged Services Codes
45-74 minutes 99415
75-104 minutes 99415, 99416
105-134 minutes 99415, 99416 x 2
Time counted toward 99415 and 99416 does not have to be continuous; however, time spent by clinical staff performing other, separately reportable services does not count toward prolonged services time.
Additional requirements for 99415 and 99416 include:
- Report 99415 once, per date.
- Neither code may be reported with 99354 or 99355.
- For prolonged services provided by clinical staff, documentation must indicate direct supervision by a physician or other qualified healthcare provider.
- Facilities are restricted from billing these services.
- 99415 and 99416 cannot be reported for more than two simultaneous patients.
Example: A patient returns to her doctor’s office for a monthly diabetes check-up. The patient reports no symptoms or other problems, aside from some weight gain. A nurse obtains the vital signs and observes that the patient has gained approximately 10 pounds since last month. Given the standing orders for a monthly fasting glucose and bi-annual A1C, the nurse takes a small sample of blood. Although the patient’s blood pressure is 118/76 and pulse is 80, the increased weight gain is concerning due to this patient’s history of insulin dependent diabetes. The nurse educates the patient on a diabetic diet and an exercise routine, as requested by the physician. Although the physician did not perform the service, the physician was immediately available in the next room, and supervised the diabetic care instructions. A total of 60 minutes was required to perform the education, obtain the blood work, and conduct the vitals.
The services are reported with CPT® 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services and 99415.
Other E/M Changes
Significant text revisions also were made to counseling risk factor reduction and behavior change intervention. The services are reported for “promoting health and preventing illness or injury.”
The risk factor reduction codes are billed without a specific illness. By comparison, behavior change interventions are reported for the “treatment of condition(s) related to or potentially exacerbated by the behavior or when performed to change the harmful behavior that has not yet resulted in illness.” These interventions must be used for “assessing readiness for change and barriers to change, advising a change in behavior, assisting by providing specific suggested actions and motivational counseling, and arranging for services and follow-up.” Any other E/M billed on the same date of service must be distinct, significant, and separately identifiable — indicated by appending modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service to the E/M service.
Example: A patient presents to the doctor’s office complaining of a persistent cough, runny nose, and joint pain. The doctor performs a detailed history, detailed exam, and moderate medical decision-making, supporting a 99214 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 detailed history; A detailed examination; Medical decision making of moderate complexity. The patient is diagnosed with bronchitis. The provider notes there is a family history of cancer and the patient smokes a pack of cigarettes per day. Given the patient’s family history and tobacco use, the provider spends 15 minutes educating the patient on the risk of lung cancer due to cigarettes and educates the patient on alternatives for the oral satisfaction obtained from smoking. The provider bills 99214-25 with 99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes.
Michael Strong, MSHCA, MBA, CPC, CEMC, is the bill review technical specialist at SFM Mutual Insurance Company. He is a former senior fraud investigator and a past EMT-B and college professor of health law and communications. Strong is a member of the St. Paul, Minn., local chapter. He can be contacted at firstname.lastname@example.org.