Extra E/M Time Not Always a Prolonged Service
Published on Sun Mar 20, 2005
Some chemo patients may need more time to review materials When your oncologist spends 80 minutes counseling a patient during what was supposed to be a level-four evaluation and management service, can you report a prolonged service code?
The answer: It depends on the types of services provided. If the oncologist spent the extra time on counseling, you should use time as a controlling factor when choosing the E/M level. However, if the visit was extended because the patient needed extra time to review treatment literature, a prolonged services code may be appropriate. Modifier -21 Can Trump Prolonged Service Before even considering prolonged service codes, you need to know a couple of vital rules. First, these codes are designed for physicians "who spend an inordinate amount of time, specifically 30 minutes, greater than the AMA's stipulated time limit for a given level of E/M service," says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa.
Translation: If the oncologist takes 10-15 minutes longer than normal to complete a level-three E/M service on an established skin-cancer patient, you should not report a prolonged service code. Instead you should:
report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity) for the service.
append modifier -21 (Prolonged evaluation and management services) to 99213 to account for the extra time.
Modifier -21 note: Including modifier -21 on the claim will not result in any extra reimbursement. The modifier will, however, show the payer that you are concerned with coding everything down to the final detail.
You must also remember that prolonged service codes are add-on codes, so they must be tagged to E/M services, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J. Do not report prolonged service codes alone, and never attach them to procedure codes. Prolonged Service Codes Depend on Setting You must know where the oncologist performed the prolonged service, or the claim could go out with the wrong codes.
Example: A stomach-cancer patient reports for an E/M service prior to an intense chemotherapy regimen. The oncologist performs a level-five E/M service that takes 45 minutes, then stays in the room with the patient while he reviews chemotherapy education literature for another 37 minutes. Level-five established patient E/M services typically take about 40 minutes, so a prolonged service code should accompany the E/M code on this claim. The claim should include: 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, and medical decision-making of high complexity) [...]
