Oncology & Hematology Coding Alert

Experts answer your prolonged care FAQs Don't let the abundance of guidelines for codes 99354-99355 deter you from properly reporting prolonged services - they may be your only means of receiving additional reimbursement for your oncologist's extra time.
 
Experts answer three frequently asked questions to help you master prolonged service coding: Q. When should we use prolonged service codes? You should report prolonged care codes 99354-99355 only for your oncologist's face-to-face patient service "that is beyond the usual service in either the inpatient or outpatient setting," according to CPT. You shouldn't use prolonged care codes when nonphysician staff treat a patient. Report prolonged services in addition to other physician services, including all levels of E/M codes, such as 99211-99215, coding experts say.
 
Use prolonged service codes as add-on codes when an E/M visit exceeds the highest level of basic E/M service, such as 99215. Bill 99354-99355 when the total duration of all physician face-to-face service equals or exceeds the E/M service's threshold time by 30 minutes. For example, if the physician's service goes 30 minutes beyond CPT's 15-minute timeline for 99213 (Office or other outpatient visit ... established patient ...), you may be able to use 99354. If the oncologist doesn't meet this standard, however, you can't bill for prolonged services, coding experts say.
 
For example, a patient with breast cancer (174.x) presents to the oncologist for the patient's first chemotherapy administration, which involves a three-hour infusion of paclitaxel (J9265). You would assign 96410 (Chemotherapy administration, intravenous; infusion technique, up to one hour) to the initial chemo administration, and then use +96412 (... infusion technique, one to 8 hours, each additional hour [list separately in addition to code for primary procedure]) for the infusion. In addition, the physician discusses with the patient the chemotherapy treatment and possible side effects.
 
After the oncologist initiates the paclitaxel infusion, the patient exhibits shortness of breath (786.05). The physician then administers emergency medications, which include IV diphenhydramine (J1200) and Solu-Medrol (J2920). The oncologist offers additional evaluation and counseling, instructing the patient that allergic reactions most often occur during the initial chemo dose. The doctor will provide premedications and closely monitor the patient during future treatments, says Margaret M. Hickey, MS, MSN, RN, OCN, CORLN, an independent oncology coding consultant based in New Orleans.
 
Overall, your oncologist spends three hours in face-to-face contact with the patient.
 
You should code the physician's E/M service as 99214 (Office or other outpatient visit ... for an established patient), which allots doctors 25 minutes to perform the service. And you could assign +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 [...]