prolonged service codes

martypope

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One of our physicians has billed a hospital consult (99255) with prolonged service codes (99356 and 99357). He also billed, several days later, a follow-up visit (99233) with prolonged E/M codes (99358 and 99359). Upon request, we sent documentation of the time and the services were denied. Medicare says they are bundled codes. We then sent the pages from the CPT showing that they are add-on codes, to be used in addition to the primary codes. Medicare is still insisting they are bundled and denying payment. Is anyone else dealing with this and have you had successful resolution?
 

mitchellde

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I have never had a problem with payment by Medicare with these codes... was total time face-to-face as well as floor time documented? did you subtract then the time alloted to the visit level? If the timing is incorrect then they will deny for inclusive. If you tell me what he documented for this maybe we can figure it out.
 

lisigirl

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I haven't had trouble getting paid from Medicare for prolonged services either. I would think the problem is either the time is not clearly documented in the note or perhaps the time billed for was too much. Based on what you wrote below, the physician spent over 3 hours face-to-face with the patient during his first visit. The documentation should clearly document the time and what was discussed during those 3 hours.

Same goes for the subsequent visit. He did not bill for face-to-face time on that date but the note should be clear on what he spent 2 hours doing on the floor (addressing this patient's case alone).

Lisi, CPC
 

martypope

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My supervisor and I are wondering if you send your claims to Madison WI, which is where are Medicare claims are processed. We have sent all the needed documentation showing the number of minutes, but are told by Medicare that they are statutorially denied, and bundled with the primary code (as B codes).
 

lisigirl

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Our Medicare carrier is Wisconsin Physician's Group. We send correspondence to Marion, IL but I'm assuming its the same carrier.

We've been paid more than once on prolonged services.

Lisi
 

mitchellde

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That can't be right. I do not bill in Wis but I have several clients/friends that do and this has never been a problem. Look at the documentation and then fight. Also remember you CMS regional office can help.
 

Karolina

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This comment may be redundant, but....
did you make sure to have more than 30 minutes above the time for the E/M service (99255, 99233 as appropriate)? The first 30 minutes are considered included in that service.
 

Karolina

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Also, so far as I know Medicare does not cover the codes without direct patient contact (face-to-face/unit time) - 99358, 99359
 

martypope

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Prolonged service codes

Yes, we did have the time beyond the primary 99255 code and the follow-up code. It was all documented, all sent to Medicare. We have sent appeals including the pages from the CPT showing that the codes are add on codes, in addition to the primary E/M codes, and are appropriately used. The isssue is that they are insisting the add-on codes are bundled with the primary codes and should not be used. They are seeming to not "get" the CPT rules.
 

mitchellde

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This is frustrating I am sure, and I am not sure whay they are not paying, the one comment about the 99358 and 99359 is correct .. Medicare across the board does not like like those but they do reimburse for the 99356 and the 99357. Can you give us a sample of one of the documentations and the time spent and maybe we can all pu our heads together and figure out what to do.
 

lisigirl

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Have you tried printing out the CCI to show that they do not bundle in CMS's own bundling system?!?!? (not that you should have to do that, they are add-on codes as you said).

If nothing else, appeal up the chain and see what happens.

Lisi
 
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