Hard Facts of Coding Prolonged Services

Hard Facts of Coding Prolonged Services

Don’t get caught without accurate documentation as OIG and health plans look at prolonged services.

When reporting prolonged services, it’s important for providers, coders, and billers to know the documentation and code selection facts to ensure proper payment.

The Basics of Prolonged Services 

Prolonged service codes 99354-99357 are used when a physician or other qualified health provider performs a prolonged service involving direct (face-to-face) patient contact that goes beyond the usual service in either the inpatient or outpatient (office, clinic, observation, etc.) setting.

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Where and When to Use: In the inpatient or skilled nursing facility setting, direct patient contact is face-to-face time and time on the unit/floor devoted strictly to that patient is reported using 99356-99357. The following cannot be billed for prolonged facility/inpatient services:

  • Time spent reviewing charts or discussing a patient with house medical staff and not with direct face-to-face contact with the patient;
  • Waiting for test results;
  • Waiting for changes in the patient’s condition;
  • Waiting for end of a therapy; or
  • Waiting for use of facilities.

In the office, clinic, or outpatient setting, direct patient contact is face-to-face time only and reported using 99354-99355. Do not bill the time spent by office staff with the patient or time the patient remains unaccompanied as prolonged office/outpatient services.

How to Use: Prolonged services are reported in addition to the primary evaluation and management (E/M) service performed at that visit. The primary E/M code must have a typical or specified time as designated in the CPT® codebook.

Depending on the place of service, 99354 or 99356 is used to report the first hour of prolonged service on a given date. Either of these codes is used only once, per date of service (first hour). To report either of these codes, the service must go at least 30 minutes beyond the normal time of the E/M code. Do not bill separately prolonged services of less than 30 minutes beyond the typical time of the E/M code.

Depending on the place of service, 99355 or 99357 is used to report each additional 30 minutes beyond the first hour. To report either of these codes, the prolonged service must go at least 15 minutes beyond the first hour of prolonged service. Do not bill separately prolonged services of less than 15 minutes beyond the first hour.

Time Must Be Documented

Prolonged services (99354, 99355 and 99356, 99357) require documented start and stop times. This requirement is identified in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM), Publication 100-04, chapter 12, section 30.6.15.1.D:

D. Documentation

Documentation is not required to accompany the bill for prolonged services unless the physician has been selected for medical review. Documentation is required in the medical record about the duration and content of the medically necessary evaluation and management service and prolonged services billed. The medical record must be appropriately and sufficiently documented by the physician or qualified NPP to show that the physician or qualified NPP personally furnished the direct face-to-face time with the patient specified in the CPT code definitions. The start and end times of the visit shall be documented in the medical record along with the date of service.

If the visit is based on counseling and/or coordination of care, start and end times must be documented, along with the attestation of time as the controlling factor. For example, “Spent 40 mins of this 75 min appt counseling and/or coordinating care regarding ____. visit start time ____ visit stop time ____.”

When using time as the controlling factor for counseling and/or coordination of care, use the highest available E/M level first, subtract that typical time from the total time, and then code based on the information given in Chart A.

Example: Established patient presents to review lab and other study findings. Document the discussion of the findings, the discussion with the patient of plan, including compliance, risks, education, etc… Document start and stop time, and state, “spent ___ mins of this ___ min appt as described ….” Provide context such as, “as described in the HPI section; as described above, etc. …”

Next, subtract the E/M time. For example, if the appointment lasted 90 minutes: The typical time for 99215 is 40 minutes; 90 minutes total minus 40 minutes for 99215 equals 50 minutes of prolonged services. In this case, report 99215 and one unit of +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).

If using the three key components of the E/M, subtract the typical time for the primary E/M visit from the total time, and then code based on the information given in Chart A.

Chart A

Correct coding and reporting of prolonged physician or other qualified health care provider service with direct patient contact in the office setting (for inpatient prolonged services substitute 99356/99357 below):

Less than 30 minutes beyond the CPT® code time = Not reported separately

30-74 minutes beyond the CPT® code time = 99354 x 1

75-104 minutes beyond the CPT® code time = 99354 x 1 and 99355 x 1

105 or more minutes beyond the CPT® code time = 99354 x 1 and 99355 x 2 (or more for each additional 30 minutes)

Example: An established patient presents and has an expanded problem-focused history, expanded problem exam, and low medical decision-making (99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 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 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 low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family).

Document the start and stop times. If the face-to-face time wasn’t continuous, document the total time, too (e.g., “Spent 95 minutes face-to-face with patient, discussed ….”). Subtract the E/M time for 99213: 95 minutes total time minus 15 minutes typical time for 99213 equals 80 minutes left over. Bill +99354 the first prolonged service hour. The remaining 20 minutes (80 – 60 = 20) are reported with +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). The final billing is 99213, +99354, and +99355.

No Modifiers Needed

Prolonged service codes don’t require modifiers, but they should be documented meticulously. The provider should document why that prolonged time was necessary. The documentation need not be lengthy, but you do need to be sure it’s detailed enough to convey how and why the prolonged time was necessary.

Final Advice: Apply prolonged service codes with prudence. These codes have higher reimbursement and health plans will scrutinize their use. Health plans may want to review your records to see if the claim is substantiated (i.e., how your time spent was documented; if the service was medically necessary; and if the service included only face-to-face patient time; or appropriate unit/floor time). No health plan expects to see prolonged services routinely. If you’re in the habit of billing these codes on a majority or high number of patients, even though it may be correct, expect health plans to challenge the charges.

Tip: Resident/Fellow time does not count as prolonged services time unless the teaching physician is present for the entire time. The physician should document their presence in the teaching physician statement. The teaching physician should document the amount of time, too, and it should match the resident’s/fellow’s documentation. In lieu of that, if the teaching physician has a resident/fellow learning, and the resident/fellow is simply present, the teaching physician must perform the documentation and include the time, as noted in this article.

Resources

CMS IOM: Pub. 100-04, chapter 12, section 30.6.15.1.D:
www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

MedLearn Matters article MM5972: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM5972.pdf.

CMS IOM: Pub.100-04, chapter 12, section 30.6.15.1.I:
www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf


Kristine Cuddy, CPC, CIMC, has 26 years of experience in the medical field. She is a healthcare compliance analyst for Michigan State University HealthTeam, provides independent consulting services, and has been a speaker and author for Michigan State Medical Society, The Coding Institute (TCI), SuperCoder.com webinars, and AAPC. Cuddy is a source for TCI’s Coding Alert newsletters, HIPAA Institute, and Part B News. She has been published in the MedEd Portal. She has served as president, vice-president, and secretary of the Lansing, Mich., local chapter, is a member of WPS GHA Medicare Part B Provider Outreach and Education Advisory Group, a member of Michigan Society of Hematology and Oncology, and is adjunct faculty at Lansing Community College, also serving on their advisory board for their medical insurance billing and coding curriculum.

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