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Urology Coding Alert

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Capture Long Office Visit Pay With +99354-+99355

Published on Tue Sep 16, 2014

Question: During a scheduled office visit of a new patient, our urologist spent an extensive amount of time with the patient. He spent a total of 114 minutes with the patient. I planned to bill the encounter with 99205 based on time since more than half the visit was spent counseling the patient. But is there a way to get additional payment for the 54 minutes past the one-hour covered in 99205?

West Virginia Member

Answer: You could use +99354 (Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management service]) for the additional time. 
 
Here’s why: When your provider sees a patient for an extended period of time, and an E/M visit code alone doesn’t accurately represent the service he provided, you may be able to report an additional prolonged service code. You will choose from the following codes based on the place of service and the time spent: 
  • +99354 
  • +99355 (...  each additional 30 minutes …)
  • +99356 (Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour …)
  • +99357 (... each additional 30 minutes …).
Don’t forget that your provider has to cross the 30-minute threshold time before the prolonged services codes kick in. So once the time with the patient goes over the threshold time, you can use a prolonged service code. If, however, the physician spends less than 30 extra minutes with a patient, you will not use +99354-+99355 or +99356-+99357.
 
Remember: Code +99354 is an add–on code, so payers will not reimburse you unless you report it with an appropriate primary code, in this case 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity ... Typically, 60 minutes are spent face-to-face with the patient and/or family).
 
Note: Your urologist’s documentation should clearly indicate the total time spent for this encounter and why it was needed. Be sure he includes how much of the encounter was spent on face-to -face counseling or coordination of care and the topic(s) of that counseling. 

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