How Do You Choose? Modifier -21 Versus Prolonged Service Codes
Published on Thu Nov 01, 2001
Oncologists routinely spend extra time with patients and their families explaining diseases and treatment. But oncology practices often code for these services incorrectly, or payers present barriers that inhibit billing for the added time spent with patients. To get paid for what you deserve, you should either use prolonged service codes (99354-99355) or use time as a factor when determining the level of an E/M visit with a Medicare or privately insured patient.
Modifier -21 (prolonged evaluation and management services), which indicates to Medicare carriers and private insurers the same thing as prolonged service codes, is similar to time-dependent E/M visit codes. However, modifier -21 deprives practices of the additional payment they deserve, says Nancy Giacomozzi, office manager for P.K. Administrative Services, a billing firm based in Englewood, Colo.
Options Depend on Carrier
To understand when to use the above codes and modifier, Giacomozzi says, oncology practices should first determine whether the patient is covered under Medicare or private insurance. For Medicare patients, the first option is prolonged service codes.
According to CPT, +99354 and +99355 are for three conditions:
When direct, face-to-face contact with the patient is beyond the usual service.
For prolonged service on a given date, even if it is not continuous.
Code +99354 should be used to report at least 30 minutes and up to one hour and 14 minutes, while +99355 is reserved for each additional 30 minutes after the first hour and 14 minutes.
Prolonged service codes are used to report added time due to unforeseen circumstances, such as the discovery of a new condition, or for the additional visit time beyond what the physician normally spends with a patient under similar circumstances. This is true for both Medicare and commercial carriers, but individual payers may not recognize these codes.
For those that do reimburse, +99354 and +99355 are add-on codes that must be used with the appropriate E/M code. For example, +99355 should be appended to 99213 (office or other outpatient visit) when the physician performs an expanded problem-focused examination that requires medical decision-making of low complexity and more than 30 minutes beyond what is normally spent performing that level of E/M.
But, if a physician performs a visit that meets the definition of 99212 a problem-focused history and exam, and straightforward medical decision-making and the total duration of the direct face-to-face contact, including the office visit, was 35 minutes 10 minutes for the visit and 25 minutes of extra time the physician cannot report prolonged service codes. This is because the total duration of direct face-to-face services did not meet the threshold time for billing prolonged services.
Also, if a physician conducts a visit that meets the definition of 99213 expanded problem-focused history and exam, and low-complexity [...]
