Primary Care Coding Alert

Question: A family physician saw a Medicare patient with an extremely complicated history and medical management decision-making in the office for 100 minutes. Based on the documentation, I can report 99215. May I report the additional 60 minutes with 99354 and 99355?


Arizona Subscriber


Answer: You are right that after coding 99215 (Office or other outpatient visit for the evaluation and management of an established patient ...), you still have 60 uncaptured face-to-face minutes. CPT allots about 40 minutes to a typical level-five established patient office/outpatient visit.

The encounter's face-to-face time, however, qualifies for only +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact ...; first hour [list separately in addition to code for office or other outpatient evaluation and management service]). Coding 99215 and 99354 allows you to capture prolonged services lasting 30-74 minutes.

Your visit, which contains 60 minutes beyond 99215's usual 40-minute service, falls within this time duration.

You should not bill +99355 (... each additional 30 minutes) with a level-five established patient visit until documentation supports a minimum of 75 minutes of prolonged services. The FP in your case would have to have spent an additional 15 minutes with the patient before you should report one unit of 99354. In other words, the visit would have to include 115 minutes or more of face-to-face time.

Bonus: Keeping track of 99354-99355's time requirements becomes an easy coding task with this chart. The Medicare Carriers Manual directs carriers to use the following threshold times to determine if the prolonged services codes 99354 and/or 99355 can be billed with the office/outpatient visit.

The CPT manual instructions confirm the above time requirements using these guidelines:

- Total duration of prolonged services less than 30 minutes is not reported separately.

- Total duration of prolonged services 30-74 minutes is reported with 99354 x 1

- Total duration of prolonged services 75-104 minutes is reported with 99354 x 1 and 99355 x 1.