Pediatric Coding Alert

Experts report uneven reimbursement for the code set

Prolonged service codes are most often used for time spent "face-to-face" with a patient, but there is also a set of codes for reporting extra time spent out of the patient's presence on an E/M service.
 
In some cases, a pediatrician may spend time away from the patient that still technically qualifies as a prolonged service -- such as when reviewing a patient's charts or discussing particulars of a patient's case with other pediatricians. When the physician provides prolonged service of this sort, report:

+CPT 99358 -- Prolonged evaluation and management service before and/or after direct (face-to-face) patient care (e.g., review of extensive records and tests, communication with other professionals and/or the patient/family); first hour (list separately in addition to code[s] for other physician service[s] and/or inpatient or outpatient evaluation and management service)

+CPT 99359 -- ... each additional 30 minutes (list separately in addition to code for prolonged physician service). Some coders, including Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., have reported trouble getting paid for these codes regardless of the carrier. (Insurers often look for proof of face-to-face service when they review a claim with prolonged service codes, which leads to denials.)

Best bet: Report 99358 and 99359 when appropriate. It may not pay off initially, but examine the Explanation of Benefits on any rejection and consistently and thoroughly pursue appeals whenever a denial is unjust.