Follow--Up on Correct Coding and Billing for Prolonged Services
Published on Mon Mar 01, 1999
In last months issue of PCA, we discussed how to code for treating an anaphylactic reaction to an allergy shot. In the case presented, the child required epinephrine, intravenous fluids, Benadryl, and continuous monitoring by the physician for about 50 minutes. The story dealt with the coding of the visit, and one recommendation was to use the prolonged services codes. We discussed the various permutations of codes that should be used for such a visit.
This follow-up gives an illustration of how you should calculate the prolonged services codes. Because CPT is somewhat confusing on this issue, we are covering it here.
When you bill an office visit and prolonged services, here is a good approach to take, says Thomas Kent, CMM, a pediatric practice advisor and a seminar leader for the Maryland-based consulting firm McVey Associates. Choose the office-visit level of service based solely on the complexity of medical decision-making, says Kent. If, beyond the services in the office visit, the pediatrician spends 30 minutes or more in consulting or attending to the patient, then you should bill prolonged services as well. Implicit in this is the need for documentation to show what time was spent over and above the office-visit portion.
Here is another criterion: If the pediatrician spends 10 to 20 minutes extra with a patient, you can upcode to the level of services based on time. (While time should not be used to determine what level of service to code, it does become an overriding factor when more than 50 percent of the visit is spent on counseling.) If the pediatrician spends 30 minutes or more in time on counseling, then bill the office visit as well as prolonged services, says Kent.
When computing all of this I do not assign a specific time to the office-visit portion, Kent notes. Usually, these office visits have two segments: the evaluation and management phasein which the patient is diagnosed and treatment methods are decided; and the treatment section.
So, when billing for prolonged services, there will be two distinct time segments: (1) The time spent in evaluation and management and (2) all other time. Only the second portion needs to be written explicitly, says Kent, although he adds that some auditors look for both times to be written. When I use prolonged services, the time spent in the workup (the E/M service) is not counted toward the prolonged services, he explains. This initial time segment is also not used for choosing the E/M. It just sits there out of the way. All other time spent in monitoring and counseling the patient [...]
