prolonged service

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Location
Sioux Falls
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We have a pharmacist that provides education on insulin pumps after the provider has seen them.
Here is a sample of the dictation:


Reason for Appointment
1. Insulin pump start


History of Present Illness
Care Coordination:
Larry and his wife present to the clinic today for an insulin pump start per Dr

Current Medications
TakingAccu-Chek Aviva Plus 3 time per day

Plavix 75 mg Tablet 1 tablet 1 time per day

Aspirin 81 mg TAB 1 tablet 1 time per day

Iron 83mg 1 tab Q Day

Vitamin E 400 unit TABLET 1 tab 2 times per day

Multivitamin 1 tab Q Day

Vitamin D3 1,000 unit tablet 1 tab 1 time per day

tramadol 50 MG Tablet 1 tablet as needed 3 times per day prn

Calcitriol 0.25 mcg capsule 2 tablets 1 time per day

Vitamin C 500 mg TABLET 2 tabs Once a day

BD U/F Short Pen Needle 31G 5/16 Miscellaneous USE TWICE DAILY

ReliOn Insulin Syringe 0.3/30G Miscellaneous USE AS DIRECTED FOR INSULIN

Simvastatin 40 MG Tablet 1 tablet in the evening Once a day

GlipiZIDE ER 10 MG Tablet Extended Release 24 Hour TAKE 1 TABLET TWICE A DAY

Gabapentin 300 MG Capsule 1 capsule at HS

Lasix 40 mg Tablet 1 tablet every day

Avapro 150 mg Tablet 1/2 tablet 1 time per day

Januvia 100 MG tablet 1 tabet 1 time per day

Coumadin 5 MG Tablet 7.5 mg on Mon and Thurs, 5 mg all other days Once a day

NovoLog 100 UNIT/ML Solution as directed via insulin pump




Past Medical History
Chronic anticoagulation
AF (atrial fibrillation)
CAD (coronary artery disease)
Hx of CABG
Antithrombotic drugs (platelet-aggregation inhibitors) causing adverse effect in therapeutic use
Type 2 diabetes mellitus with diabetic chronic kidney disease
Diabetes mellitus type 2 with neurological manifestations
Insulin long-term use
DM type 2 causing vascular disease
DM retinopathy
OSA on CPAP
DM neuropathy, type II diabetes mellitus
CKD (chronic kidney disease) stage 3, GFR 30-59 ml/min
HTN (hypertension)
Current use of beta blocker
Hyperlipidemia
On statin therapy
RLS (restless legs syndrome)
Aspirin long-term use
Morbid obesity
History of amputation of foot


Allergies
Mirapex: pain in legs : Side Effects


Assessments
1. Type 2 diabetes mellitus with diabetic chronic kidney disease - E11.22 (Primary)

Treatment
1. Type 2 diabetes mellitus with diabetic chronic kidney disease
Start Bayer Contour Next Test Strip, as directed, In Vitro, 8 times a day, 30 days, 250, Refills 6 months
Stop Accu-Chek Aviva Plus, 3 time per day
Stop BD U/F Short Pen Needle Miscellaneous, 31G 5/16, USE TWICE DAILY
Stop GlipiZIDE ER Tablet Extended Release 24 Hour, 10 MG, TAKE 1 TABLET TWICE A DAY
Stop Januvia tablet, 100 MG, 1 tabet, oral, 1 time per day
Notes: Pt and wife here today for insulin pump hook up per Dr ________ will provide follow up. Provider in the room for 15 minutes to address all questions. Educated pt was previously on Lantus and Humulin R. Reviewed with provider prior to hook up and he felt that novolog would be best, since the pump uses only fast acting insulin. Dr also instructed patient to stop Januvia and Glipizide. Educated pt will have follow up with provider on 1/8, but can call before if any questions or concerns. Educated pt will need to check his BG readings about 8 times a day and bring all the readings to his appointment with provider . Educated pt this will help provider make adjustment to the pump settings. Educated pt we start the pump with conservative settings and will likely change over time. Insulin pump settings: basal: 1.7 units/ hour Insulin to carb: 1 units/15 grams CHO Correction factor: 1 unit to decrease BG by 20 mg/dl Discussed introduction to insulin pump therapy, basic features, basic programming, bolus wizard calculator, reservoir and infusion sets, trouble shooting for site, tubing, insulin, pump and optimizing options for the pump. Briefly discussed temp. basal feature, dual/square wave bolus and the option to link the meter to the pump. Pt did want to link the meter and this was completed. Called prescription to pharmacy for strips for new meter. Our registered dietitian met with patient and wife for 20 minutes to discuss carb counting. Pt and wife verbalized understanding of this information. Educated pt that lots of information was discussed and may feel overwhelmed. Provided pt with 800 number for 24 hour medtronic customer service for pump questions and discussed when to contact his provider. Pt stated had read through the book and now was feeling a little better about all the information. Educated to review books and online training at anytime, but can call with questions or concerns as well. Total time spent- 2.5 hours.




Procedure Codes
99354 PROLNG SVC OFFICE OP DIR CONTACT 1ST HR
99355 PROLNG SVC OFFICE OP DIR CONTACT EA 30 MINUTES



Follow Up
1/8 with provider

So they want to code the 99215 along with the prolonged service codes. They bill it out under the provider and not the pharmacist. I have a problem with this as it states that the provider is only in the room for 15 minutes. I have tried to address this with my supervisor but they say as long as it is billed out under the provider it is ok. I feel that the codes RUV's are for provider work and not the pharmacists work. Just wonder what any one else thinks about this.
 

mitchellde

True Blue
Messages
13,505
Location
Columbia, MO
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No you cannot bill this as a 99215 nor can you use prolonged time for the pharmacist face to face time. Did the physician document any part of this note? These Cade's state in the description that they are face to face with the physician. If the pharmacist does not have his own NPI then the highest level that could be billed is the 99211. If the physician documented a separate note then you might be able to use the new prolonged staff time codes as long as the physician is in the office at the same time.
 
Last edited:
Messages
26
Location
Sioux Falls
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He co signed the note but did not have any note of his own. The manager thinks as long as he co signed it then it is ok. The physician is on site but like the note says he only spent 15 minutes with the patient.
 

mitchellde

True Blue
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13,505
Location
Columbia, MO
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No this cannot be an incident to service. The pharmacist must have his own NPI and Bill under his own number. Without an NPI the only service that could be billed as incident to is a 99211. With an NPI it could be an incident to service for greater than a 99211 however many payers do not allow higher than a 99214 for incident to. In addition prolonged time is never allowed as incident to. To use the new prolonged staff codes the provider would need an independent assessment note as a provider level. By using the providers NPI you are representing this as a physician service and the documentation cannot support this. Why not look at the 98960 for education and training for self management?
 
Last edited:

thomas7331

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I agree with Debra completely. This could be a serious compliance issue. A large physician group I worked with in the past was audited for billing pharmacist services under a physician's ID. When it came to light, they had to pay back a large sum of money and the managers of the responsible area lost their jobs.
 
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