Primary Care Coding Alert

Documentation of physician time is critical in charging for prolonged services, which are face-to-face, as is the evaluation and management (E/M) code for outpatient care, says Barbara Cobuzzi, CPC, CHBME, president of Cash Flow Solutions, a medical billing and consulting firm in Lakewood, N.J.

E/M codes used in the inpatient environment are based on time spent on the patients hospital floor or unit, so when using prolonged services with inpatient E/M codes, remember that face-to-face time must be at least 30 minutes, she explains.

During an office or other outpatient visit for the E/M of a new patient 99201-99205 (which require three key components: ranging from a problem-focused to comprehensive history, a problem-focused to comprehensive examination and straightforward decision-making to one of high complexity), physicians typically spend 10, 20, 30, 45 and 60 minutes face-to-face with patients for each of the five levels of E/M service. When direct contact with the patient exceeds the standard amount of time by 30-60 minutes on a given date, you may use 99354 (prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour) in addition to the E/M code.

The same rules apply to inpatient services, 99221-99223 (initial hospital care, per day, for the evaluation and management of a patient which requires these three key components: ranging from a detailed to a comprehensive history, a detailed to a comprehensive examination and medical decision-making that is straightforward or of low complexity to one of high complexity). In coding for these three levels of inpatient service, a prolonged service code, 99356 (prolonged physician service in the inpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., maternal fetal monitoring for high-risk delivery or other physiological monitoring, prolonged care of an acutely ill inpatient]; first hour) may only be used if physicians spend 60, 80 or 100 minutes, respectively, at the bedside and on the patients hospital floor or unit.

If outpatient services exceed 74 minutes beyond the typical time allotted for each E/M level, code 99355 (each additional 30 minutes) in addition to 99354. On the inpatient side, code 99357 (each additional 30 minutes), in addition to 99356.

Scenarios for Using Prolonged-Service Codes

Scenario #1: A 35-year-old established female patient with diabetes visits her FP for a three-month check-up to review her diet, lifestyle and medications, which takes 35 minutes. Her blood sugar is out of control, so the FP spends a total of an hour with the patient. The FP should code 99214 (office or other outpatient visit for the evaluation and management of an established patient [...]