EM Coding Alert

Location key to correct code choice.

CPT^® guidelines for reporting different kinds of prolonged services are lengthy and daunting. Get those rules wrong, and you could be looking at denial and costly rework.

But knowing when you can apply them can add significantly to your bottom line. So, read on and take this advice for flawless prolonged service coding.

Want to Document Prolonged Services With Direct Patient Contact? Do This

When the physician or other qualified health professional performs prolonged services involving direct patient contact “that is provided beyond the usual service in either the inpatient or outpatient setting,” you will choose from the following E/M codes, according to the guidelines:

• +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))
• +99356 (Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient Evaluation and Management service))
• +99357 (…; each additional 30 minutes (List separately in addition to code for prolonged service)).

Don’t miss: A key distinction between the codes mentioned above relates to where the prolonged services are provided, according to Cynthia A. Swanson, RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Nebraska.

Codes +99354 and +99355: You should report +99354 and +99355 only in the office or other outpatient setting, according to the guidelines.

Codes +99356 and +99357: On the other hand, you should report +99356 and +99357 to represent the total duration of time the physician or other qualified health professional spent at the bedside on the patient’s floor or the unit in the hospital or nursing facility. So, you would report +99356 and +99357 only when the physician has admitted the patient to the hospital or to observation status.

Remember +99354-+99357 Are Add-On Codes

When you look at codes +99354-+99357, you will notice the + symbol, which means these are add-on codes. An add-on code is a code that cannot stand alone, explains Linda Martien, CPC, COC, CPMA, AAPC Fellow. It is always used with or added to the base code.

For instance, 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity) would be your base code and +99354 would be the add-on code if the provider spent 30 minutes to one hour in prolonged service, according to Martien.

Coding tip: Always report the add-on prolonged services in addition to the primary procedure, such as the designated E/M service on any level, psychotherapy code 90837, family psychotherapy code 90847, and any other services the physician provides at the same session, according to the guidelines.

Grasp Importance of Time

It is important to understand that the prolonged service codes +99354-+99357 are defined by time, Swanson says.

“As such, practitioners should routinely record the total duration of time they spend face-to-face with the patient in the office or other outpatient setting,” Swanson adds. “In the hospital or nursing facility setting, the practitioner should document the floor or unit time spent to coincide with the reported/billed CPT^® prolonged service codes.”

Caution: You cannot separately report a prolonged service that is less than 30 minutes’ total duration on a given day because “the work involved is included in the total work of the evaluation and management codes,” according to the guidelines.

Turn to +99354 or +99356 to report the first hour of prolonged service on a given date, dependent upon the place of service (POS). However, you should report either code only once per date, even if the time the physician spends is not continuous on that date, per the guidelines.

Look to +99355 or +99357 to report each additional 30 minutes beyond the first hour, dependent upon the POS. You may report either code for the final 15-30 minutes of prolonged service on a given date. However, you cannot separately report a prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes.

Don’t miss: “There is a common misunderstanding that prolonged services with patient contact can only be billed after the time for the highest E/M code of the code set (e.g., 99205, 99215, or 99223) has been exceeded,” explains Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington. “This is only true if the entire encounter is based on time (i.e., based on counseling and/or coordination of care). If the base E/M code is based on the elements (history, exam, decision making) then prolonged services can be added to any E/M code once the typical time for that code has been exceeded.”