Orthopedic Coding Alert

Key: Count only face-to-face time and document necessity.

When your physician performs an E/M service and spends more time than usual, you can may be able to claim for this additional time and effort spent. You can turn to the following add-on prolonged service codes:

• +99354 (Prolonged evaluation and management or psychotherapy service[s] [beyond the typical service time of the primary procedure] in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service])
• +99355 (…each additional 30 minutes [List separately in addition to code for prolonged service]).

Do not lose focus on high level E/M codes: You are not correct if you think that prolonged care services can only be reported with the highest level of E/M code, such as 99205 (Office or other outpatient visit for the evaluation and management of a new patient…) or 99215 (…an established patient…) for office services.

Fact: You can report prolonged care services with any level of E/M code. “While the level of E&M service may be chosen based on time, this applies when at least half of the face-to-face time is spent in counselling and coordinating care,” says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison. “If this does not apply, then the prolonged service add-on codes may be appended to a lower level of service.”

Example: The E/M code 99203 typically applies to E/M lasting 30 minutes. For extended time, you will have to look at the total time spent and then report +99354 and +99355 according to the CPT^® time rules.

Follow these three key tips to better understand whether or not you can report prolonged care codes in a particular situation and, if so, what codes you need to report depending on the duration of the session.

Tip 1: Go by the Clock for Prolonged Services

When reporting prolonged services in addition to an E/M code, you will need to count the time your clinician spent face-to-face with the patient to analyze if you can report the prolonged service codes +99354 and +99355. You will need to follow CPT^® time rules to understand whether or not you can report +99354 and +99355 for the extended period of time. If you look at the descriptor of the add-on prolonged services code +99354, you will locate a time duration as “first hour” of service. However, you needn’t always report this code only when your provider performed the prolonged service for one hour. Below are the CPT^® requirements for timing of prolonged services:

Mark the minimum of 30 minutes: Your provider must have done the evaluation or management typically for 30 minutes longer than the E/M time you would otherwise be reporting. For example, you may read that a patient visit qualified for CPT^® 99214, which has a typical time assigned by AMA of 25 minutes. In this case, your provider needs to spend minimum of 55 minutes to begin billing prolonged service codes. “This is typical for reporting time-based codes. A threshold of more than half of the time of the service must be met before one can report the time-based code,” Przybylski says.

“Prolonged services of less than 30 minutes are not separately reportable,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “Per CPT^®, prolonged services of less than 30 minutes are part of the E/M code that you are otherwise reporting for the encounter.”

For 30 to 74 minutes: You can report +99354 when the extended E/M service lasts between 30-74 minutes longer than the typical time of the E/M code you are otherwise reporting.

For 75 to 104 minutes: You report the add-on code +99355 in addition to +99354 when the session lasts between 75-104 minutes.

Beyond 104 minutes: For every 30 minutes of extended duration beyond 104 minutes, you report an additional unit of +99355.

Note: Keep complete documentation of the time your physician spent with the patient for E/M service.

Tip 2: Collate Total Time on a Calendar Day

Your physician needn’t perform the prolonged E/M continuously at any point on a single day. The prolonged E/M may be done in split sessions. In this case, you can claim for the total additional time spent.

Here are two key rules that you should follow:

• Report the base add-on code, +99354, only once for the patient on one calendar date of service for prolonged care services.
• Collate all the time spent in the various sessions throughout the day and calculate total time before you can report +99354 and the additional unit(s) of +99355.

Caution: Do not report the add-on code +99355 without reporting the base add-on code +99354 for the first 30-74 minutes of prolonged services. “Based on the rule for add-on codes, since 99355 is added-on to 99354, both add-on codes must be reported in addition to the E/M service performed in order to describe prolong services that exceed the base E/M duration beyond 74 minutes,” Przybylski says.

Tip 3: Check and Complete Documentation

When submitting a claim for prolonged service, you can’t just mention the time your physician spent. For assured payment, you need to also describe the services your physician provided and the medical necessity of the prolonged service. Make sure your documentation is complete for these essentials.

Only face-to-face services qualify: You can submit the prolonged care service codes +99354 and +99355 only when your clinician is performing the E/M service face-to-face with the patient. You cannot count any time that you clinician spends non face-to-face, i.e., if your physician spends time in the absence of the patient in reviewing some records, engages with and consults with other clinicians about the patient’s condition, you cannot add this time into the time spent face-to-face with the patient.

Note: If you check the descriptor of the code codes +99354 and +99355, you can confirm that the codes apply to only ‘direct service.’

What can do you for non-face-to-face services? You have a different set of add-on codes that you can try to report for prolonged services that your physician performed not being face-to-face with the patient. These add-on codes are:

• +99358 (Prolonged evaluation and management service before and/or after direct patient care; first hour)
• +99359 (…each additional 30 minutes [List separately in addition to code for prolonged service]).

As with face-to-face prolonged care services, you report the add-on code +99358 for the first hour of non-face-to-face services that your physician provides to the patient and then report +99359 for every additional 30 minutes of service beyond the first hour.

Caveat: Many payers do not provide coverage for non-face-to-face prolonged care service codes, +99358 and +99359. Check payer policies and coverage guidelines to see if these services are covered before you report these codes. “The requirement of face-to-face time for CMS coverage is applicable to most E&M services,” Przybylski says. “A notable exception are critical care services, which are also time-based codes, but include non-face-to-face services attributable to the critical care of the specific patient being treated.”

Find out what Medicare says: Medicare is one of the payers that has historically not paid separately for codes +99358 and +99359, considering payment for the codes “bundled” with the payment Medicare makes for other services. However, in the proposed rule for the 2017 Medicare physician fee schedule, the CMS proposed to begin paying for these codes in 2017. You can access the proposed rule online at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1654-P.html.

Another update: On November 1, 2016, the CMS released its final rule Hospital Outpatient Prospective Payment Changes for 2017. You can access this rule on: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-11-01-3.html.