2021 CPT/PROLONGED NEW PT VISIT

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Please help... New patient, visit that lasted 225 minutes. The patient received Spravato so had to have the observation time involved with that. We are looking at billing 99205 for the 74 minutes , and then adding the 99417 x ? it would be like 10! :-( Is this correct ? IS there a limit on the 99417's? My thought is also going to all the webinars of "If your billing for a service, injection, administration of something, that would be double dipping "? I've also read not that some commercials aren't paying for so file the G code ? Not sure how to code this to give to my billing dept. Any help would be great appreciated!! Thank you!
 

Cheezum51

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Remember that the Time element for code selection only involves Doctor or other QHP time. So, for example, if the patient was just sitting in some part of your office after administration and the doctor or QHP wasn't sitting there the who time, that time doesn't get added into your total time. If the doctor or QHP was with the patient the entire time of the visit, then all the time would be billed as you said.
 

SharonCollachi

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The total time is the time that your licensed professional (physician, PA, NP) spent on the patient on one day, MINUS any time that is billed separately. If an injection took 5 minutes, then subtract that from the total time. And like the previous poster mentioned, just sitting in your office is not counted. It has to be time that the provider is doing something for the patient, whether that is chart review, dictation, face-to-face, etc. They cannot spend that same time doing something else (seeing another patient).
 

lakooms

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The total time is the time that your licensed professional (physician, PA, NP) spent on the patient on one day, MINUS any time that is billed separately. If an injection took 5 minutes, then subtract that from the total time. And like the previous poster mentioned, just sitting in your office is not counted. It has to be time that the provider is doing something for the patient, whether that is chart review, dictation, face-to-face, etc. They cannot spend that same time doing something else (seeing another patient).
Hey Sharon, how do you convince the provider of this? I have this service at my clinic and have not been able to explain why we have to be face to face.....by a provider and not clinical licensed staff.
 
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Hey Sharon, how do you convince the provider of this? I have this service at my clinic and have not been able to explain why we have to be face to face.....by a provider and not clinical licensed staff.
From the guidelines: "For office or other outpatient services, if the physician’s or other qualified health care professional’s time is spent in the supervision of clinical staff who perform the face-to-face services of the encounter, use 99211."
In general I would check the payer's guidelines. I'm only familiar with Medicare, which uses a time-based E/M HCPCS code for the service. However if your private payer uses CMS' medically unlikely edits you'll be capped at 4 UOS (60 minutes) for the prolonged service and will have to appeal anything over that.
 

SharonCollachi

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Hey Sharon, how do you convince the provider of this? I have this service at my clinic and have not been able to explain why we have to be face to face.....by a provider and not clinical licensed staff.
Billing based on time doesn't have to be just face-to-face time. Time spent reviewing records, dictating, all that counts as long as its on the same day.

There are different codes for clinical staff, there is incident-to (but not on a new visit), there are ways to capture clinical staff time. What you don't get to bill for is doing nothing... which is what is happening when the patient is just sitting there, perhaps getting vitals by a medical assistant every 15 to 30 minutes.
 

lakooms

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Billing based on time doesn't have to be just face-to-face time. Time spent reviewing records, dictating, all that counts as long as its on the same day.

There are different codes for clinical staff, there is incident-to (but not on a new visit), there are ways to capture clinical staff time. What you don't get to bill for is doing nothing... which is what is happening when the patient is just sitting there, perhaps getting vitals by a medical assistant every 15 to 30 minutes.
Hey Sharon, hypothetically you have a schedule for spravato patients (that could be established patients) the RN rooms the patient and monitors vitals periodically throughout the 225 minutes. the provider reviews records and physically checks in with the patient for up to 30 minutes face to face time, would you say that is reasonable? These could be psych patients where the ketamine is keeping them from needing to be hospitalized. The provider usually checks in between other patients they have on their own personal schedule, but the RN/LPN is the one mostly checking in---which each staff is technically operating under the supervison/license of the MD. is that what you mean makes it ok to bill 99215/99214 +99415/99417 several units of observation codes? The RN/LPN walks the patient out of the office.
 
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Hello, I've also found that with the 99417 a lot of commercial payers only want to pay up to 4 units. My office has to bill out 8 units, so we always run into issues with this. Has anyone found a way to combat this or just appeals?
 
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