Practice Management Alert

Question: My physician spent 105 minutes with a new patient in the office. Is 99205 the only code I can bill?

Massachusetts Subscriber

Answer: No, you should also look at the prolonged office visit codes +99354-+99355 (Prolonged physician service ... requiring direct [face-to-face] patient contact ... ).

Here's why: Code 99205 (Office or other outpatient visit for the evaluation and management of a new patient ... Physicians typically spend 60 minutes face-to-face with the patient and/or family) requires 60 minutes of face-to-face time. But if your physician spent 105 minutes with the patient, then you can bill 99205 for the first 60 minutes plus +99354 to capture payment for the extra time.

Remember that codes +99354-+99357 are time-based and are add-on codes. You do not need to append a modifier to these codes and you should not decrease their reimbursement when billed with other primary E/M codes.

Important: Remember that there is a 30-minute threshold time with the prolonged services codes before those codes kick in. In other words, include 30 minutes more beyond the usual time for the reported E/M service before using the prolonged services codes.

In this case, you should report 99205 for the first 60 minutes, add 30 minutes threshold time making the time for the initial visit 90 minutes, and then add +99354 for the additional 15 minutes to reach 105 minutes.

Caution: You cannot bill 99205 based just on time unless your physician documents that he spent over 50 percent of the total time on counseling and/or coordinating care for the patient and documents the total time of the encounter. You also have to show medical necessity and documentation must reflect the history (comprehensive), exam (comprehensive), and medical decision making (high). It is not enough to bill 99205 just because the time was spent with the patient and the total time is documented. You have to meet the requirements for 99205 to bill a 99205.