Wiki prolong service

[veeramani14]

Hi all,

can anyone advice me how to bill prolonged service codes 99354-99357 with office visit(99211-99215, 99201-99205).

is there any possibilities to add 25 modifier to prolonged services?

one of my carrier saying,
procedure code 99354 is not likely to be covered as it may be included in the allowance for another service. that is office visit.

(If you agree with this advice and do not want to bill the procedure, please remove the charge.
If you would like to document the procedure for tracking purposes and do not expect to be paid, please set the charge to $0.)

what can i do for this?


thanks,
veera.

 

[OCD_coder]

You did not state what your carrier was. Sp I am taking a poke at my own personal experience.

Anthem BCBS policy is the prolonged service codes are typically inclusive of the primary E&M code. They require clinical documentation submitted with the claim, otherwise it will be denied.

Also, they have announced that they have a reference list of diagnosis that might be expected when reporting prolonged services.

Reference Policy RE.028 "Prolonged Services Coding"

Modifier 25 - Per CPT description is for a separate or signifianctly identifiable E&M by the same physician on the same DOS. The prolonged service codes are an extension of the E&M and it would not be appropriate to use a mod-25 just to try and get payment. There should be a minor procedure performed on the same day that is significant or separate from the E&M work performed.