Cardiology Coding Alert

Cardiologists who spend extended time counseling a patient or patients family may benefit financially from appropriate use of prolonged services codes. Many practices are unfamiliar with these evaluation and management (E/M) services, however, and often cardiologists dont document their time adequately which is the critical compliance guideline for billing these services and is essential to successful reimbursement.

CPT divides prolonged services into two subcategories: direct, or face-to-face contact, and without direct contact. For reimbursement, only the face-to-face codes are significant, as most carriers wont pay for nondirect prolonged services.

The four face-to-face codes are further categorized as inpatient or outpatient, as follows:

99354 prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g, prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient evaluation and management service];

99355 ... each additional 30 minutes [list separately in addition to code for prolonged physician service];

99356 prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service [e.g., maternal fetal monitoring for high risk delivery or other physiological monitoring, prolonged care of an acutely ill inpatient]; first hour [list separately in addition to code for inpatient evaluation and management service]; and

99357 ... each additional 30 minutes [list separately in addition to code for prolonged physician service].

Document All Time Spent With the Patient

Prolonged services, along with critical care and care plan oversight, are one of three E/M code categories that are entirely time-based. Therefore the regular E/M categories history, exam and medical decision-making do not apply when billing for prolonged services. Instead, the amount of time spent face-to-face with the patient determines which code to bill.

Simply stating that the cardiologist spent extra time with a patient does not justify prolonged services. Rather, precise documentation is necessary, says Susan Callaway, CPC, CCS-P, a coding and reimbursement specialist in North Augusta, S.C.

To charge for each additional half-hour of prolonged services, at least 15 minutes of the additional 30 minutes claimed must be documented. With any time-based code, whether critical care or prolonged services, when 30 minutes of the first hour [30-74 minutes HCFA time] is documented, youve met the documentation requirements for the first hour, Callaway explains. The same applies for the next 30 minutes, she says. If 75 minutes of face-to-face contact are documented, the cardiologist can charge for another half-hour.

Time should be documented in minutes, and noting the start and stop times although not required is also a good idea, Callaway adds.

Dont Use Prolonged Services Codes On Their Own

Prolonged services codes are add-on codes, meaning they cannot be billed alone and must accompany another E/M service, explains Terry Fletcher, BS, CPC, CCS-P, an independent cardiology coding and reimbursement specialist in Laguna Niguel, Calif. And because these codes are time-based, they can be added only to E/M services that include a time component (reference time), such as hospital admissions (99221-99223), inpatient followup care (99231-99233), consults and office visits (99201-99205, 99211-99215).

Note: In cases where more than 50 percent of the physician/patient or physician/family encounter is spent counseling or coordinating care, time supersedes history, exam and decision-making and becomes the principal factor in determining the level of E/M service. In such cases, prolonged services may be billed only if the time exceeds the reference time of the highest-level code in the category by at least 30 minutes. If the additional time was spent for reasons other than counseling or coordination of care, the E/M level is based solely on history, exam and medical decision-making, and a higher-level visit should not be claimed. Instead, prolonged services may be billed in addition to the appropriate E/M code if 30 minutes or more additional time has been spent.

Billing a prolonged service code as an add-on to an emergency department (ED) visit code (99281-99285) is inappropriate because these codes include no time component and, therefore, there is no way to indicate what was prolonged.

The cardiologist may, however, bill prolonged services for time spent in the ED if he or she determines that the patient should be admitted.

For example, a patient arrives at the ED with chest pain, dizziness, palpitations and shortness of breath. She cannot speak English and only recently moved from another state to be closer to her children. An interpreter is required to communicate and, due to cultural differences, the patient is reluctant to divulge health information. The cardiologist must spend an inordinate amount of time extracting the patients history and locating her records. By contacting her previous cardiologist, the treating cardiologist is finally able to obtain a copy of her chart, which indicates that she had undergone an abnormal stress test but had declined further evaluation. Eventually, the cardiologist determines that the patient may suffer from unstable angina and admits her.

In this situation, if the total time the cardiologist has documented is equal to or exceeds 30 minutes beyond the reference time for the admit, the first hour of prolonged services (99356) may be billed. The cardiologist performed a level-two admit, which includes a reference time of 50 minutes. If 80 minutes spent with the patient can be documented between the ED chart and the admission chart (50+30=80), both 99222 (initial hospital care, per day, for the evaluation and management of a patient. . . .Usually, the problem[s] requiring admission are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patients hospital floor or unit [emphasis added]) and 99356 can be billed.

Note: Because counseling and coordination of care did not exceed 50 percent of the total time spent with the patient in this situation, the additional time contributes to prolonged services, not to raising the level-two admission to a level three.

Office visits, too, include reference times. For example, an 87-year-old new patient with multiple medical problems presents at the clinic for an evaluation, accompanied by his family. The cardiologist determines that the patient suffers from ischemic cardiomyopathy with congestive failure and chronic atrial fibrillation. Recent lab work also documents renal failure and anemia.

After a comprehensive evaluation, the cardiologist explains possible evaluation and treatment options to the family. End-of-life issues are discussed, including do not resuscitate (DNR) and power of attorney. As is often the case in such situations, the patient and his children are conflicted about which course to pursue.

In this situation, the cardiologist very likely spends 90 minutes with the patient counseling and/or coordinating care. Even with a level-five established patient code (99205, office or other outpatient visit for the evaluation and management of a new patient. . . . Physicians typically spend 60 minutes face-to-face with the patient and/or family [emphasis added]), only the first 60 minutes of the encounter have been coded. The remaining 30 minutes may be billed using prolonged services code 99354.

Apply Nondirect Time to Original E/M service

The 50-minute reference time for a level-two hospital admission includes not only face-to-face time but also floor time on the unit. The documented time to support billing with prolonged services codes 99354-99357, however, must be face-to-face time spent with the patient.

For instance, if the cardiologist spends a total of 80 minutes with the patient, at least 30 minutes must be direct or face-to-face contact to bill a prolonged service. The cardiologist, therefore, should document ordering labs or consults, conferring with other physicians or staff, and evaluating lab results, other chart notes and consults already performed, as these are all part of the floor time for any inpatient service and may be counted as part of the admission, Fletcher says.

Time included in the admission spent on the floor talking to the family about the patients condition may also be included. Encounters with family members should take place in the patients ward. Meetings in the chapel or the ED while doing other work do not apply. Cardiologists also should note in the patients chart that the admit is a continuation of the time already spent in the ED, even though there is a separate ED chart. Therefore, the inpatient chart can stand on its own.

Avoid Overuse

Fletcher recommends that practices not use prolonged services codes every chance they can. Overuse will definitely attract unwanted attention, including audits. Although there are no official guidelines or restrictions on the number of E/M claims that include prolonged services, they usually should not make up more than a tiny percentage of total E/M services billed.