Primary Care Coding Alert

Question: A patient presents with encopresis, or severe constipation. The family physician inserts a prescription suppository four times during the same day and spends almost five hours of office time performing the procedures. How should I bill for the in-office insertions? Should I separately report the procedures in addition to an E/M service?

Iowa Subscriber

Answer: CPT does not include a suppository insertion procedure code, so you should combine the day's E/M services, which will probably result in a level-five office visit (99205, Office or other outpatient visit for the evaluation and management of a new patient; or 99215, ... of an established patient). To capture direct patient-physician time beyond the time CPT indicates the E/M service typically includes, use prolonged service codes +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 (list separately in addition to code for office or other outpatient evaluation and management service); and +99355 ... each additional 30 minutes (list separately in addition to code for prolonged physician service). If the patient is an established patient, you should report 99215. Because CPT indicates that this service typically takes 40 minutes, you have 260 unclaimed minutes (5 face-to-face hours x 60 minutes = 300 direct minutes, minus 40 minutes for 99215). Submit 99354 x 1 for the first 60 prolonged service minutes and 99355 x 7 for the additional 200 prolonged service minutes in addition to 99215.