Neurology & Pain Management Coding Alert

Prolonged services codes (99354-99359) are a good option when seeking reimbursement for significant extra time spent caring for patients. For example, when treating children, neurologists often need to spend much more time, and a higher-level E/M code may not fit the circumstances, resulting in inaccurate coding.

Billing for Prolonged Services

You need to remember that the prolonged services codes are add-on codes, which means they cannot be billed on their own but must accompany another E/M service, says Kim Rivera, general manager and co-owner of Sound Management and Billing Services Inc., an organization that bills for neurologists and other specialties in Seattle. Because these codes are time-based, they can be added only to E/M services that have a time component or reference time built in, such as hospital admissions, inpatient follow-up care, consults or office visits.

To bill for prolonged services, the neurologist must document in the patients medical record the additional time spent. He or she also needs to report what occurred and why the visit went beyond the allotted time.

There are two sub-categories of prolonged services: with direct (face-to-face) contact (99354-99357) and without direct (face-to-face) contact (99358-99359).

For example, 99354-99357 can be used when a physician performs a level-four, new patient evaluation (99204) on a child with cerebral palsy (343.9). However, because of the childs fear and inability to communicate with the neurologist, the visit takes 80 minutes instead of the normal 45 minutes. In this case, the doctor would bill 99204 to cover the first 45 minutes of the visit and 99354 for the additional 35 minutes.

Codes 99358-99359 can be used when a neurologist performs a level-four, established patient visit (99214) on a patient with Alzheimers disease (331.0). After the
25-minute exam, the physician spent 45 minutes with the patients daughter to review complex, detailed medical reports and completes a comprehensive treatment plan. In this case, the neurologist would bill 99214 to cover the first 25 minutes and 99358 for the additional 45 minutes.

According to CPT 2001, 99358-99359 are used when a physician provides prolonged service not involving direct care that is beyond the usual service in either the inpatient or outpatient setting. Claims using these codes are rarely paid, says Melody Mulaik, MSHS, CPC, president and co-founder of Coding Strategies Inc., an Atlanta-based coding and reimbursement firm that supports more than 500 physicians nationwide.

Do Not Bill with Emergency Department Codes

Some coders have had claims denied when billing a prolonged services code as an add-on to an emergency department (ED) visit (99281-99285). Because the ED codes have no time component or reference time. There is no way to indicate what was prolonged, so these claims will be denied [...]