Cardiology Coding Alert

For cardiologists who often find themselves spending an inordinate amount of time with patients during office or inpatient visits, prolonged service codes (99354-99357) can increase reimbursement. (For more information on prolonged services without direct patient contact, see article on page 53.) For example, 99354 (prolonged service in the office or other outpatient setting requiring direct patient contact) and 99355 (each additional 30 minutes) each pay about $75; and 99356 (prolonged service in the inpatient setting requiring direct patient contact) and 99357 (each additional 30 minutes) each pay about $85. However, many practices often use these codes incorrectly, warns Ray Cathey, PA-C, president, Medical Management Dimensions, a coding and reimbursement consulting firm in Stockton, CA.

Medicare carriers tell me that physicians are not billing for prolonged services when they can and are trying to use them when they shouldnt, he says.

Greg Schnitzer, RN, CPC, CPC-H, CCS-P, agrees. Theres a lot of confusion about these codes. Some of it is due to the gray areas of coding, but most is due to misunderstanding, says the audit specialist at the Office of Audit & Compliance, at the University of Pennsylvania in Philadelphia. (For help on distinguishing between prolonged care and counseling and coordination of care, see related story on page 53.)

Cathey and Schnitzer offer these tips to help cardiology coders use prolonged service codes correctly:

1. Understand what CPT means by prolonged services. There is a difference between having a visit which is merely complicated/labor intensive and a visit which is prolonged, explains Schnitzer. Prolonged signifies a duration of time, not a profound intensity of service.

A prolonged service, according to the CPT, occurs when a physician provides direct patient contact that is beyond the usual service.

What is a usual service? The CPT notes these typical times in the definitions of levels of evaluation and management (E/M) services. For example, a level-three office visit for a new patient (99203) should take about 30 minutes. (For a timetable of E/M codes that affect prolonged service codes, see page 51.)

2. Track total time. Selecting the correct prolonged service code is based on total duration of time on a particular date. The service does not have to be continuous, says Cathey. For example, a physician may return to the room periodically to check on a patients condition following an elective cardioversion procedure.

Keep track of and document the start and stop time of each visit so they can all be added up to determine the prolonged time for that day, stresses Schnitzer. Also, if you are audited, the auditors will look at these start and stop times to determine if the service should have actually been coded as prolonged.

Thats why [...]