Wiki Pediatric Prolonged Visit


Local Chapter Officer
Best answers
Per CPT, the E/M codes can be used for meeting with the patient and/or family. The prolonged services codes are split into "direct" or "without direct" patient contact. We have a minor who was brought in and the provider did examine the patient but then sent her out of the room so that she could discuss the history of possible sexual abuse indicated by the mother. Most of the 90 minute visit was spent with the mother only. Would we use the "Prolonged E/M service before and/or after direct patient care, first hour" since the child was not in the room OR since she was still in the office and the provider was talking with the mother would that be considered "direct" contact since the patient is a minor?
Thank you,
The E/M guidelines state:
"When counseling and/or coordination of care dominates (more than 50%) the encounter with the patient and/or family (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time shall be considered the key or controlling factor to qualify for a particular level of E/M services. This includes time spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members (eg, foster parents, person acting in loco parentis, legal guardian). The extent of counseling and/or coordination of care must be documented in the medical record."

If you bill 99215, which is 40 minutes, you could then add on 99354 for the additional 50 minutes. (99354 can only be billed if the extra time is 30 minutes or more, which is not the case here).