Neurology & Pain Management Coding Alert

Strict reimbursement guidelines sometimes cause physicians to feel they are giving away their time when an office or inpatient procedure runs longer than expected. When extra time is spent with a patient that involves direct (face-to-face) patient contact beyond the usual service, you often can obtain fair reimbursement for extended procedures by using prolonged service codes (99354-99357).

For example, you might have to take extra time with a cerebral palsy patient because the patient isnt able to cooperate during an exam. That might qualify as a prolonged service, says Shelly Kramer, MPA, RRA, audit compliance specialist with Boston Medical Center.

Choosing Correct E/M Code

Be sure to select the appropriate evaluation and management (E/M) codes for the service. This is essential because prolonged service codes are always used as an adjunct to other service codes (i.e., the prolonged service codes cannot be claimed by themselves).

Note: The prolonged service codes are not just for counseling services but can be used for any extended service with an office E/M or outpatient code.

Keep in mind that codes 99354-99357 are used with the E/M service code for additional time spent face-to-face with the patient. However, the time spent must exceed the time allowed in that E/M code by at least 30 minutes before the prolonged service codes may be used. According to the CPT manual, code 99354 or 99356 is used to report the first extended hour of prolonged service on a given date. Either code may be used to report a total duration of prolonged service of 30 to 60 minutes on a given date, even if the time spent by the physician is not continuous on that date. You must document your time to warrant the use of these codes.

Code 99355 or 99357 is used to report each additional 30 minutes beyond the first hour (99355 is used in conjunction with 99354, and 99357 is used in conjunction with 99356). Either code may also be used to report the final 15 to 30 minutes of prolonged service on a given date. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.

Eight Rules for Using Prolonged Service Codes

1. The physician actually must be present with the patient. Codes 99354-99357 are very clear: This is face-to-face time between the physician and the patient. The doctor cant just be writing in the patients records in his office, says Kramer. The doctor is seeing the patient and administering care.

Kramer warns that physicians should guard against claiming unearned face time. An auditor will look at a physicians schedule for the whole day. Theyll look at how many patients he [...]