Part B Insider (Multispecialty) Coding Alert

Published on Fri Jun 27, 2003 PDF

If your physician is spending more than the usual amount of time with a patient, you could let reimbursement slip through your fingers if you don't bill correctly.

Medicare will pay for prolonged service for visits that last past certain time frames. The rules are different for inpatient and outpatient visits (see chart on next page), but the constant is that spending extra time should yield extra payment.

Private payers generally don't reimburse prolonged service codes (99354-99357), so coders who are new to Medicare may not understand all the ins and outs of billing for them, says Barbara Cobuzzi, president of Cash Flow Solutions in Lakewood, N.J. "It's an area where [many] people lose out on an opportunity for reimbursement," she says.

Generally, you can use prolonged service codes for an evaluation and management visit that goes on longer due to counseling. For example, a cancer patient may need extra counseling, as may a patient who is resisting surgery and needs a lot of answers.

You can't add 99354-99357 to hospital observation (99217-99220), observation or inpatient services (99234-99236), critical care (99291-99292), or emergency department services (99281-99285), says Tara Conklin, certified coder with Clark-Holder Clinic in LaGrange, Ga.

It's very important to provide detailed documentation with these claims, Cobuzzi adds. It should include the start and stop times of the direct patient care, plus the total visit time, and what the physician did to justify the length of time spent with the patient.

You don't necessarily have to use prolonged service codes with the highest level of E/M codes, Cobuzzi says. For example, CPT 99213 has a reference time of 15 minutes, so if you spend 45 to 90 minutes with a patient, you can bill 99213 and 99354. This works if you performed an expanded problem-focused history and then spent more time talking with the patient about surgical options and counseling her about surgery. The total visit time could be 50 minutes, with 15 minutes for E/M and 35 minutes for counseling.

Many coders would report that visit as 99215 and document that the physician spent more than half the visit time on counseling and coordinating care, Cobuzzi says. But 99215 in the office setting pays only $116.98, whereas 99213 pays $51.13 and 99354 pays $121.02, adding up to $172.15.

Others express more caution about using prolonged service codes too often. "I would only use the prolonged service codes when absolutely necessary," says Terry Fletcher, healthcare coding consultant with Medlearn Inc. in South Orange County, Calif. She'd use them, for example, with an asthma patient with shortness of breath who comes in for a routine visit, and the doctor gives the patient oxygen or an inhaler and checks on her periodically over a 90-minute period.

 "When you add a time-based code, your original code becomes time-based," Fletcher says. In other words, the original E/M code must include only face-to-face time to add up to 15 minutes.

In the office setting, though, you have to be careful to add up only the time the physician actually spent with the patient. The amount of time the patient spent reading a magazine doesn't contribute to the calculations for prolonged service codes. The doctor practically has to punch in and out every time she goes into the treatment room with the patient.

In the hospital setting, the prolonged service portion can count the amount of time the doctor was on the floor if the encounter goes past a certain length. The initial "prolonged service portion" that goes past the reference time must be face-to-face time, but the reference time can include floor time. In other words, the doctor can spend an hour with the patient, of which 30 minutes is face-to-face time, and you can bill 99232 (Subsequent hospital care) plus 99354 for that encounter, Cobuzzi says.

You can add 99354 only to an E/M code, not a surgical code, Cobuzzi says. If you need to spend a long time after a surgery with a patient, you still can't bill for 99354 unless you also performed E/M services before or after the surgery.