EM Coding Alert

Hint: different providers mean different documentation.

When an E/M service goes longer than usual, you know you have to reach for a prolonged service add-on code to describe the full extent of the service.

But before you open up your CPT^® code book, you need to make sure you know who provided the service and what they did. So, read on and add to you understanding of prolonged service claims.

Separate Types of Prolonged Services

When you are coding for prolonged services in an office/outpatient setting, you’ll choose from the following codes:

• +99354 — Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) 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 or psychotherapy service)
• +99355 — … each additional 30 minutes (List separately in addition to code for prolonged service)
• +99415 — Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour (List separately in addition to code for outpatient Evaluation and Management service)
• +99416 — … each additional 30 minutes (List separately in addition to code for prolonged service).

So, what’s the difference between +99354/+99355 prolonged services and +99415/+99416 services?

“The difference between these two sets of codes for prolonged services would definitely be who provided the service,” explains Manny Oliverez, CPC, CEO of Capture Billing & Consulting, Inc., in South Riding, Virginia.

“Codes +99354 and +99355 are for prolonged services by a physician or other qualified health care provider — such as a nurse practitioner or physician assistant,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “Codes +99415-/+99416 are for clinical staff — such as a registered nurse [RN] or a licensed practical nurse [LPN]. One other difference is that +99354/+99355 include both prolonged E/M and psychotherapy, whereas +99415/+99416 only reference E/M.”

You must report +99354 and +99355 for office/outpatient E/Ms that have “a time component, and the typical time of the E/M service code billed must be exceeded by 30 minutes,” according to Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico.

“With +99415 and +99416, a clinical staff member provides the service — but it must be reported with an E/M service that has a time component where the billing provider has billed the E/M service,” Witt continues. For this pair of prolonged service codes, you must exceed the E/M service time by 45 minutes before reporting them.

Also: “The physician or NPP [nonphysician practitioner] must be present to provide direct supervision of the clinical staff” during +99415/+99416 encounters, Oliverez says.

Remember Patient Contact, or Forget These Codes

Also remember that +99354, +99355, +99415, and +99416 all require direct patient contact, reminds Oliverez. For prolonged services that occur before or after direct patient care, you’d use 99358 (Prolonged evaluation and management service before and/or after direct patient care; first hour) and +99359 (… each additional 30 minutes [List separately in addition to code for prolonged service]).