Part B Insider (Multispecialty) Coding Alert

Published on Fri Feb 03, 2006 PDF

Hint:  Face-to-face time in an outpatient setting does not have to be continuous

Don’t be left in the dark about coding your physician’s extra time. Follow our expert advice to make every minute count--and to get your claim right the first time.

1. Make sure the time qualifies for prolonged services.

First, know that when dealing with CPT time-based codes, the codes meet their time requirement when half of that time has been documented and spent.

But before even considering prolonged services codes, know this vital rule: Prolonged services codes are for physicians who spend an inordinate amount of time, at least 30 minutes, greater than the American Medical Association’s  (AMA) time limit guidelines for a given level of E/M services , says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting, Inc. in Lansdale, PA.

Example: If a physician takes 10-15 minutes longer than normal to complete an E/M service, you cannot report a prolonged service code. Check out the charts on the next page to see how many minutes should be in your E/M documentation to apply +99534 (Prolonged service in the office or other outpatient setting…) or +99536 (Prolonged physician service in the inpatient setting).

Remember that +99354 or +99356 is for the first hour of prolonged service time and that you should report +99355 or +99357 for each additional half-hour, respectively.

Important: Prolonged service codes are add-on codes, which means you must tag them to other E/M services, reminds Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, NJ.

Mistake: If you think modifier 21 (Prolonged evaluation and management services) is an easy fix to account for any extra E/M time that doesn’t meet the prolonged services code time requirements, think again. First, you can only use modifier 21 for top-level E/Ms. But more importantly, modifier 21 is informational only, so it won’t help round up any extra dollars for your practice.
 
2. Code to the setting.

Once you havve verified that a prolonged service code is time-appropriate, make sure you know where the physician performed the services as these codes are setting-dependent. Codes +99354 and +99355 are for office/out patient settings, and +99536 and +99357 are for hospital/inpatient settings.

The setting also comes into play when counting your physician’s time. With prolonged hospital/inpatient services, the E/M can represent “floor time,” but the office/outpatient E/Ms must represent face-to-face time only.

Example: A stomach cancer patient reports to an outpatient oncologist’s office for an E/M service prior to an intense chemotherapy regimen. The oncologist performs a level-five E/M service that takes 20 minutes, and then she stays in the room with the patient to review chemotherapy education literature for another 55 minutes. A level-five established patient E/M has a guideline of about 40 minutes, so the total time of this E/M (75 minutes) qualifies as outpatient prolonged services since it was all face-to-face. You would report 99215 (+99354).  

Important: Unlike a visit that’s based on counseling time, the doctor isn’t required to separate the E/M and counseling time in the documentation. However, the doctor must justify why there was extra time. In the example above, the oncologist should record the total time and indicate what she did during the extra time.

3. Remember, face-to-face time is cumulative.

All of the prolonged service codes require “face-to-face” patient care, but that doesn’t mean the time must be continuous, Falbo says.

Example: A pulmonologist sees an established patient in a morning office visit for a level-three E/M that includes a chest x-ray review. This visit lasts 20 minutes. But the physician decides that the patient needs another x-ray. The patient leaves to get the x-ray and returns that afternoon, whereupon the pulmonologist reviews the x-ray with the patient and discusses treatment options. This visit lasts 30 minutes. You could report 99213 +99354 even though the time the pulmonologist spent with the patient wasn’t continuous.

Why? The doctor spent a total of 50 (face-to-face) minutes with the patient, and that is more than 30 minutes of the AMA’s time guideline for 99213.

But what if in the above example, the first visit was 45 minutes and the second visit was 50 minutes? You may be tempted to report 99213 +99354 twice, but this is incorrect, says CPT 2006. Report 99213 +99354 only once, and use +99355 for each additional 30 minutes.

Don’t overlook: Again, inpatient E/M codes are based on floor time. However, when using prolonged services with inpatient E/Ms, face-to-face time must be at least 30 minutes. But reference time for the E/M can include floor time.

4. Know your right to appeal.

Medicare carriers pay for prolonged services in most areas, but not all carriers will be so quick to reimburse for prolonged services. For instance, a coder in Springfield, IL notes that her carrier considers prolonged services a non-covered Medicare charge.

Critical: If this is the case for you, know that you can--and should--appeal. You may have to take your case to the QIC or administrative law judge level, but Medicare is required to pay, experts assert.

Helpful: For all other insurance, try calling some payors, Falbo suggests. “Query your top payor classes on prolonged services and obtain something in writing as an addendum to their managed-care contract.”