Wiki Still confused by Prolonged Services

[PVAzCPC]

I code for Psychiatry and have struggled with this since January:

Is it true that Prolonged Services codes (99354-55 Outpatient) can ONLY be used IF the PROVIDER DOCUMENTS COUNSELING AS THE MAJORITY OF THE ENCOUNTER ("greater than 50% of today's visit spent on counseling and/or coordination of care")?

Yes or no?

 

[LouiseR1]

No, you are thinking of level selection based on time. If the provider documents that time spent was counseling as majority of the encounter, you can select an E&M level based on time. otherwise, prolonged services are used to report total duration of face to face time spent on a given date even if time spent is not continuous.

Louise

 

[PVAzCPC]

No, you are thinking of level selection based on time. If the provider documents that time spent was counseling as majority of the encounter, you can select an E&M level based on time. otherwise, prolonged services are used to report total duration of face to face time spent on a given date even if time spent is not continuous.

Louise

Ok, so are you saying that if the E/M meets criteria for, say 99214, based upon key components (but does not meet 99215 based upon key components), but provider spent extra time going over childhood etc (remember this is Psych ), I can assign 99354 to capture the extra, say 30 minutes, to the CPT 99214 on a total appt duration of, say 55 minutes?

 

[LouiseR1]

According to the CPT book,
"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...)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 responsilbility for the care of the patient or decision making whether or not they are family members....The extent of counseling and or coordination of care must be documented in the medical record."
In other words, if provder spent more than 50% of the visit counseling on the childhood etc....you can select the level of care based on time, but it has to be documented. However if the time spent was obtaining history, doing the physical exam, or other (besides counseling) then bill the E&M based on documentation with the prolonged care....


hope this helps....
Louise