Prolonged Services Are for Extra Time Spent Face-to-Face
Published on Fri Mar 01, 2002
Physicians and coders are reluctant to report prolonged services codes (99354-99357) because of lack of knowledge regarding the guidelines. When, for instance, is it appropriate to claim prolonged services rather than to calculate an E/M visit using time as the determining factor? Do prolonged services stand alone, or must they be reported with another E/M service? If they are reported with other E/M services, which codes apply? What documentation is necessary? Do most payers reject prolonged services claims? Clearly, the confusion surrounding these codes is legitimate. However, prolonged services are too useful to dismiss as insignificant or overly complicated.
Getting to Know 99354-99357
Prolonged services are a unique category of E/M codes that describe face-to-face, physician-to-patient contact "that is beyond the usual service in either the inpatient or outpatient service," according to CPT. Such situations may occur if a patient is noncompliant or requires special attention due to a mental or physical handicap, or if the surgeon must explain complex diagnoses, treatment options or substantial lifestyle changes to the patient. Applicable codes include:
99354 Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting); first hour (list separately in addition to code for office or other outpatient evaluation and management service)
99355 each additional 30 minutes (list separately in addition to code for prolonged physician service)
99356 Prolonged physician service in the inpatient setting, requiring direct (face-to-face) patient contact beyond the usual service (e.g., maternal fetal monitor-ing for high-risk delivery or other physiological monitoring, prolonged care of an acutely ill inpatient); 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 physician service).
These services are reported in addition to other physician services, including E/M services at any level, and 99355 and 99357 may be reported only in addition to 99354 and 99356.
Got the Time?
Prolonged services codes are time-based and may only be appended to other E/M codes that include a reference time (without this time component, there is no way to define a service as "prolonged"), advises Linda Laghab, CPC, coding department manager for Pediatric Management Group at Children's Hospital, Los Angeles. Specifically, section 15511.1 of the Medicare Carriers Manual (MCM) dictates that 99354 and 99355 may only be reported in addition to 99201-99205 and 99212-99215 (Office or other outpatient visit) or 99241-99245 (Office or other outpatient consultation). Similarly, 99356 and 99357 must accompany a claim of 99221-99223 (Hospital inpatient services), 99231-99233 (Subsequent hospital care), 99251-99255 (Initial inpatient consultations), 99261-99263 (Follow-up inpatient consultations), 99301-99303 (Comprehensive nursing [...]
