2016 Brings Opportunity to Increase Revenue 

2016 Brings Opportunity to Increase Revenue 

Meet criteria to report two new codes for prolonged clinical staff observation services in the outpatient and office settings.

Prior to 2016, observation care services provided by clinical staff under the supervision of a physician or other qualified healthcare professional were considered part of office or outpatient services. This year, two new add-on codes are available for reporting prolonged clinical staff observation services in the outpatient and office settings:

+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)

These codes may be reported when the primary service provided to the patient by the physician or other qualified healthcare professional in an office or outpatient setting results in clinical staff providing observation care beyond the typical time ordinarily included within the evaluation and management (E/M) service.

Vital Definitions

Clinical staff includes a person who works under the supervision of a physician or other qualified healthcare professional and who is allowed by law, regulation, and facility policy to perform or assist in a specified professional service, but who does not individually report that professional service. Other policies may also affect who may report specific services.

Direct supervision means the physician or other qualified healthcare professional must be present at the site where the service is provided and is readily available to furnish assistance or direction.

Note the Difference

Prolonged service codes +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) and +99355 Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (List separately in addition to code for prolonged service) require direct patient contact (face-to-face) between the physician and the patient. The new prolonged services codes are useful when the patient requires further clinical observation, but face-to-face time with the physician or other qualified healthcare professional isn’t necessary.

Follow Examples for Applying Codes

A 21-year-old male comes to his primary care physician’s office complaining of painful abdominal cramps and persistent diarrhea for the past two days. He has not been able to hold down any food or drink in 24 hours. The physician performs a detailed history, detailed examination, and medical decision-making of moderate complexity. The physician diagnoses the patient with viral enteritis and decides to begin oral rehydration. The clinical staff monitors and observes the patient for three hours.

Although the patient is still under the care of the physician, direct face-to-face time with the physician or other qualified healthcare professional is no longer required — the clinical staff is under the supervision of the physician or other qualified healthcare professional.

The total time of the primary service is used to determine when the prolonged service time begins, as shown here:

Total Duration of Prolonged Services (in Excess of Primary E/M Service) Code(s)
Less than 45 minutes Not reported separately
45-74 minutes (45 minutes to 1 hour 14 minutes) +99415 x 1
75-104 minutes (1 hour 15 minutes to 1 hour 44 minutes) +99415 x 1 and +99416 x 1
105 minutes or more (1 hour 45 minutes or more) +99415 x 1 and +99416 x 2 (or more, for each additional 30 minutes)

In the above example, the E/M service is reported with 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. Counseling and/or coordination of care with other physicians, other qualified health care professionals, 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. Typically, 25 minutes are spent face-to-face with the patient and/or family. Prolonged services begin after the 25 minutes of face-to-face time that is customary for the physician to spend with the patient during the primary service. CPT® +99415 is reported after clinical staff has spent at least 70 minutes face-to-face with the patient (45 minutes after the initial 25 minutes).

Reporting Criteria

The following criteria must be met to report +99415 and +99416:

  1. The place of service must be in an office or outpatient setting.
  2. Face-to-face time with the clinical staff must be beyond the typical face-to-face time of the E/M service on a given date (Note: Time does not have to be continuous).
  3. The physician or qualified healthcare professional must be present to provide direct supervision of the clinical staff.
  4. +99415 is for the first hour of prolonged clinical staff service on a given date (Note: A service of less than 45 minutes total is not reported separately).
  5. +99416 is for each additional 30 minutes.
  6. Prolonged services of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately).
  7. +99415, +99416 may not be reported for more than two simultaneous patients.
  8. Facilities may not report +99415 and +99416.

 

Oby Egbunike, CPC, COC, CPC-I, CCS-P, is a licensed ICD-10-CM instructor for AAPC. She has a Bachelor of Arts in Business Administration with concentration in Health Information Management from Northeastern University Boston. Egbunike has over 10 years of experience in healthcare management, coding, billing, and revenue cycle. She is the coding manager for professional coding and education at Lahey Health. Egbunike is a member of the Boston, Mass., local chapter.

Resource: CPT® Professional Edition 2016

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