Ensure Proper Reimbursement With Prolonged Service Codes

You can optimize reimbursement for infectious disease (ID) services by using prolonged service codes (99354-99357). ID physicians sometimes forget to use these valuable codesand then realize, often too late, that they were entitled to hundreds of dollars in additional compensation from payers.

For example, ID physicians can increase payment by using the prolonged service codes for services provided to AIDS patients Why? Because these cases usually involve complex medical and psychological support. This initial prolonged management visit sets the stage for the entire course of the treatment of the patient with full-blown AIDS.

Its at this stage of the diagnosis that the AIDS patient begins to realize legitimate fears about the nature of the disease. However, ID physicians can use this prolonged visit to become partners in care with the patient. In addition, experts say, patients who have experienced this prolonged ID physician/patient interaction have proven to be far more compliant in taking their medicationsthus extending their life span.

Prolonged service codes are add-on codes used to report time spent by ID physicians performing medically necessary E/M services, whether continuous or not, that exceeds the typical time of the E/M service by 30 minutes or more. CPT codes 99354-99357 are reported (see box on page 21), in addition to the level of E/M service code identified by the performance and documentation of the three key components of history, physical examination and medical decision-making.

Prolonged evaluation and management (E/M) services involving direct, face-to-face physician contact are reported using CPT codes 99354-99357. These codes are used to report services beyond the usual service involving medically necessary prolonged face-to-face contact.
Code 99354 identifies the first 30 to 60 minutes of prolonged services in the outpatient setting.

Use CPT code 99355 to report each additional 30 minutes of prolonged care in the outpatient setting. To identify prolonged inpatient services, use code 99356 for the initial 30-60 minutes and code 99357 for each additional 30 minutes. Prolonged services of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes are not reported separately.

The face-to-face time does not have to be continuous, notes Sally J. Trew, RN, CPC, medical reimbursement consultant for Alpern Rosenthal & Company, in Pittsburgh. The time identified by these codes is the total face-to-face time spent on a given date that is in excess of the average time identified by CPT for the specific E/M service, she explains.

For example, Trew says, say the physician performs a level three, established patient office visit, 99213, and the total duration of medically necessary face-to-face services (including time to perform 99213 elements) was 70 minutes. CPT identifies the average time of a 99213 encounter [...]

- Published on 2000-05-01