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 Schnitzer suggests staff and physicians can most accurately track time by jotting a note in the patient chart upon entering and leaving the room. Documentation must show you tracked time in and time out, he says.
Note: Chart notes such as complex/complicated or thorough/detailed/involved do not necessarily warrant prolonged, warns Schnitzer. The complexity of the physician/patient interaction or the value of such interaction to the patient is irrelevant to the auditor, he says. The determining factor in billing a prolonged service code is whether a visits length of time was prolonged beyond the normal amount of time for that E/M code.
3. Other documentation needed. Cathey points out that, in addition to time, documentation needs to include who was present (i.e., patient and/or family members) as well as what was discussed. Who, what, and whenthose are the three elements needed to support a prolonged service code, he adds.
You need all three, stresses Schnitzer. Suppose the entry reads, Gave full written and verbal instructions to restrict sodium intake, walk two miles daily, and obtain home blood pressure monitor for daily monitoring.
That may show the physician is thorough, but it does not document he or she spent more than 30 minutes above and beyond the usual amount of time spent during that E/M visit, he explains.
Note: The Medicare Carrier Manual (MCM), Section 15511.1 (c), discusses the documentation standards for prolonged services: Do not require documentation to accompany the bill for prolonged services unless the physician has been targeted for medical review. Advise physicians that to support billing for prolonged services,
the medical record must document the duration and
content of the evaluation and management code billed and that the physician has personally furnished at least 30 minutes of direct service after the typical time of the evaluation and management service had been exceeded by at least 30 minutes.
4. Never use a prolonged service code by itself. Prolonged service codes are add-on codes, explains Schnitzer. They must be billed in conjunction with the appropriate E/M code, he stresses.
For example, 99354 and 99355 must be billed with one of the following:
office or other outpatient services (99201-99215)
office or other outpatient consultation (99241-99245)
comprehensive nursing facility assessment
Likewise, 99356 (prolonged physician service in the inpatient setting requiring direct patient contact) and 99357 (each additional 30 minutes) must be billed with one of the following:
hospital inpatient services (99221-99233)
initial inpatient consultations (99251-99255)
follow-up inpatient consultation (99261-99263).
One vexing issue with billing prolonged care occurs when the prolonged care is rendered in the office setting, but the patient is later admitted. For example, if after spending time over and above the typical length for an office visit for a patient with rhythm problems, the cardiologist admits the patient and intends to follow the care. How does he or she get reimbursed for the extra time in the office?
The CPT guidelines indicate you cant use inpatient prolonged care codes (99356 and/or 99357) in this instance because the care took place in the office. But they also indicate you cant use outpatient prolonged care (99354 and/or 99355) with the inpatient admit code.
This situation is one of those gray areas of coding that has not been clarified, Schnitzer says.
Yet you shouldnt donate those extra minutes without a fight, recommends Susan Callaway-Stradley, CPC, CCS-P, senior consultant for Medical Group of Elliott, Davis and Co., LLP, an accounting and consulting firm in Augusta, GA. Go ahead and submit the inpatient admit code and the appropriate outpatient prolonged service code, rather than misrepresenting the site of service, she says. You can either file a paper claim and attach a cover letter explaining the scenario that caused you to select these codes, or you can file electronically.
If you choose to submit a cover letter, try including the following statement: We are billing for the initial hospital care (list appropriate initial hospital care code) in addition to prolonged care rendered in the office (list appropriate prolonged care code). We understand that CPT states only one E/M code can be billed per day. Therefore, we are not billing for the office visit (list level of code you would have billed). However, we are billing for the ___ minutes that exceed the typical time for that office code. The enclosed documentation shows the duration of the office service, the circumstances under which it was necessary, as well as where the service was rendered. Thank you for considering the additional payment of $____.
Whether you submit a paper or electronic claim, Callaway-Stradley warns, expect to appeal. The key to winning the appeal is to have clear documentation that explains what happened to make the service prolonged as well as when and where it occurred, she says.
5. Count carefully. The prolonged service codes can only be billed if the visit lasted 30 minutes (or more) longer than the usual amount of time required by the E/M exam, Schnitzer says.
If the extra amount of time for the visit was less than
30 minutes, you cant bill for [the extra time]. It is considered included in the total work of the E/M exam codes, explains Cathey.
Be sure to account for all the time throughout that daywhether continuous or notby using the prolonged services codes that represent 30-minute increments: 99355 or 99357. (These can only be reported in addition to a basic prolonged service code99354 or 99356.)
Either of the incremental codes can be used to report the final 15-30 minutes of prolonged service on a given date, explains Cathey. Prolonged service of less than 15 minutes beyond the final 30 minutes is not reported separately. (Use the chart on page 50 to determine which basic prolonged service code to bill as well as which incremental codes to bill.)
Note: Modifier -51 (multiple procedures) should not be appended to prolonged service codes.