Gastroenterology Coding Alert

Question: Our office sees a lot of hepatitis C patients. Last week, an established patient reported for a follow-up visit to check on her condition and get treatment options. The gastroenterologist performed a level-five E/M service during the visit, which took 90 minutes. Can we report a prolonged services code in addition to the E/M code?

Vermont Subscriber Answer: Yes, you can. Report 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity) with +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact ...; first hour) attached.

Why?: The prolonged service code is permissible in this instance because the visit took 90 minutes, 50 more than the CPT-estimated 40 minutes a 99215 service typically takes; 99215 only accounts for 40 minutes of time spent with the patient, and 99354 accounts for the remaining 50 minutes.

Before you use a prolonged service code, make sure you have:

 attached the prolonged service code to an E/M code. These are add-on codes, so never report them alone or with other types of services.

 provided at least 30 minutes of prolonged service. If you provide any less than that, just report the E/M code. (Exception: If the gastroenterologist provides a level-five  E/M service, you may account for less than 30 minutes of prolonged service using modifier -21 [Prolonged evaluation and management services]. See "You Be the Coder" for more modifier -21 information.

 furnished the claim with down-to-the-minute documentation. Have your gastroenterologist document the start and stop times of the prolonged service, and make sure the documentation reflects the exact amount of prolonged care provided.