Pediatric Coding Alert

When a pediatrician spends an extended amount of time with a patient, he or she may bill for the extra work by using the prolonged services codes (99354, 99355). 99354 can be used beginning at 30 minutes and covers the time spent with the patient through 75 minutes. If the visit is longer than 75 minutes you would bill 99354 and 99355 (99355 is for each additional 30 minutes, but can be used for the final 15 minutes of prolonged services that have extended beyond one hour).

In some cases, the pediatrician will spend a prolonged amount of time on a patients care, but not all of that time in direct, face-to-face contact, notes Sharon Diaz, office manager of Pediatrics of South Austin (TX), a three-pediatrician group. This illustrates a key issue complicating the use of the prolonged services codes.

Take the example of a patient who is having an asthma attack and needs nebulizer treatment, she explains. The pediatrician spends more than 30 minutes altogether on the patient, but not all face-to-face.

He examines the child, then goes to the lab and orders the nebulizer and other labs. The neb treatment is done for about 15 minutes. Then the doctor listens again. It only takes a couple of minutes to determine whether treatment is needed again, Diaz explains. Therefore, does the 30 minutes include the procedure or just the exam?

For an asnwer we consulted Tina Cressman, pediatric billing specialist for Cooper Pediatrics, a 45-pediatrician multi-specialty group in Cherry Hill, NJ. According to Cressman, the pediatrician can only bill for the prolonged time he or she spends directly in contact with the patient. And, that time must be scrupulously documented.

The prolonged services codes can be lucrative for a pediatric practice because they can be used in addition to office-visit codes, but knowing what qualifies as prolonged is tricky. Its important to note that the first 30 minutes of an office visit do not count. (After 30 minutes, you can bill 99354 for the first hour, according to CPT.) And, its also important to note that all of the reported time does have to be face-to-face if the physician is going to use these codes. However, the care does not have to be delivered continuously.

Note: The CPT 99358 -99359 (prolonged physician service without direct, face-to-face patient contact) can be used when a physician provides prolonged service not involving direct care, according to CPT, but, this would not cover a service in which the physician saw the patient part of the time.

Billing Prolonged Services

Here are some tips for correctly using these codes.

1. Track the time in, time out. The pediatrician should document when he goes into the examining room and when he leaves, says Cressman. Youre supposed to document the time spent with the patient for the face-to-face code, she says. If you go into the room at 10:05, examine the patient for 10 minutes, and then order the 15-minute treatmentwhich is given by a nurseyou are not face-to-face for more than 10 minutes. If you come back at 10:45 and stay until 11:00 examining the patient and talking to the parent, you still have only spent 25 minutes with the childnot enough time to bill any prolonged services code. If, however, you come back at 10:45, leave at 11:00 while the patient has another treatment, come back at 11:30, leave, again, at 12:00, come back at 12:20, and leavefinally dismissing the patient at 12:40you end up spending a total of an hour and a half with the patient. Then, you can indeed bill for 99354 (one hour) and 99355 (half hour).
Remember, prolonged services codes are to be used in addition to office-visit codes.

Tip: You can also jot down approximate face-to-face times for each encounter with the patient on the day in question. Just make a notation in the margin of the chart notes. Then, you can add up the column of times. If it is 30 minutes or greater, you can add 99354 to the office visit. To support the time indicated, you will need sufficiently detailed documentation.

2. Use documentation to convince the payers. Some insurance carriers just dont like the prolonged services codes. In order to get paid, you probably will have to submit documentation, says Cressman. This is where your notes on the time you entered and left the examining room are important. A lot of the carriers just dont recognize the codes, Cressman tells us. It isnt right, so you can fight it. Medicaid does recognize the prolonged services codes, notes Cressman.

Tip: Even if you arent getting reimbursed for prolonged services codes, use them anyway, the billing specialist advises. Many practices may end up eating the charges. But, having the codes in their records is necessary for tracking productivity. Otherwise, when a pediatrician spends a lot of time with a patient, it may look as if he or she isnt seeing enough patients that day. The codes also can be used internally to track time. We can see which pediatrician is spending how much time on what, says Cressman, noting that the trend in managed care is toward holding physicians responsible for their time. These internal records are often needed to explain productivity figures, particularly in a practice that has a high percentage of acutely ill patients who will often require more prolonged services.

3. Remember to count separated time. Sometimes a patient may come in twice during the same day, and this can be a perfect situation for the prolonged services codes. Here is an example. The child presents to the office in the morning with asthma. After two nebulizer treatments, he goes home. In the afternoon, however, he returns; the asthma is worse. He is sent home after three nebulizer treatments, this time with a home nebulizer. The afternoon session included instruction by the pediatrician to the mother on how and when to use the home nebulizer. What the coder should do is add up the time for each face-to-face encounter with the pediatrician as if it were all one continuous visit. If the total is over 30 minutes you can add 99354 to the office visit.

Tip: Also note that the two visits are considered one visit because they took place on the same day and the patient was seen by the same physician. This would probably justify a 99215 for the office visit.