What Modifier will Medicare accept for 99355 Prolonged Services?

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We have been billing 99354 and 99355 for Prolonged services related to Pain Management and Ketamine Infusion. 99354 is for the 1st hour (30 - 74 minutes) of Prolonged E&M time requiring direct contact, and 99355 is for each additional 30 minutes. Medicare is limiting 99355 to 3 units and said they need a modifier for more. We have tried 25, XU, 59, and 76 and so far it is no good. Both BCBS and UHC have been paying up to 7 units for 99355. Can anyone help me with getting more time paid?

Thank you,

Cameron Moriarty, CPC
 
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We have been billing 99354 and 99355 for Prolonged services related to Pain Management and Ketamine Infusion. 99354 is for the 1st hour (30 - 74 minutes) of Prolonged E&M time requiring direct contact, and 99355 is for each additional 30 minutes. Medicare is limiting 99355 to 3 units and said they need a modifier for more. We have tried 25, XU, 59, and 76 and so far it is no good. Both BCBS and UHC have been paying up to 7 units for 99355. Can anyone help me with getting more time paid?

Thank you,

Cameron Moriarty, CPC

99355 has an MUE of 4, which might explain part of the problem. Modifiers aren't normally applied to add-on codes, so I'm not sure why MC is telling you to do that, but since 99354 and 99355 are both add-on codes, what E/M code are you using for the first part of the encounter? Are you also billing the infusion administration codes?
 
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I mostly use 99203/99213 (other levels as appropriate). I do bill for the Infusion with 36000, 96374, 93041, 96365, 96366, plus drug codes.
 
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I mostly use 99203/99213 (other levels as appropriate). I do bill for the Infusion with 36000, 96374, 93041, 96365, 96366, plus drug codes.

99203/99213 bundle with both 96374 (Standards of medical / surgical practice) and 96365 [and 96366] (Misuse of column two code with column one code), which means the prolonged services will bundle also.
So it looks like what MC is saying is that the services you're reporting with 99203/99213, 99354, and 99355 are already reported in codes 96365 and 96366; basically they're saying you're reporting the same service twice. A modifier can break the bundle but you'd have to show that the E/M charges, including the prolonged services, contain separately identifiable work than what's described in 96365 and 96366. You'd add the mod to the E/M charge if the documentation supports it.

For instance, say you report 96365 and 96366 x 2, totaling 3 hours. (setting the 99213 aside for a second) Say you also report 99354 and 99355 x 4, totaling 3 hours. The prolonged services are face-to-face time with the patient, so essentially what you're saying is that the provider spent 3 hours of evaluation with direct patient contact on top of the direct patient contact and work included for the infusion services. 99354 and 99355 include "beyond the typical service time of the primary procedure" in the description, so it would appear as though the patient had infusion for 3 hours and then spent an additional 3 hours face to face with the provider for E&M services or vice versa. IMO, I don't think using the prolonged codes is appropriate if you're matching them to the infusion hours.

"HCPCS/CPT codes have been written as precisely as possible to not only describe a specific procedure but to also avoid describing similar procedures which are already defined by other HCPCS/CPT codes. When a HCPCS/CPT code is reported, the physician or nonphysician provider must have performed all of the services noted in the descriptor unless the descriptor states otherwise. (Occasionally, a HCPCS/CPT code descriptor will identify certain services that may or may not be included.) A HCPCS/CPT code should not be reported out of the context for which it was intended."

(There's some other bundles in there depending on what charges you're billing together)
 

mitchellde

True Blue
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I agree, if you are charging the 99213 plus the 99354 and say 7 units of 99355 plus the 96365 and the 96366 all for one patient then you are indicating a patient that was in the office for almost 7 hours.
15 minutes for the 99213
60 for 99354
30x7 = 3.5 hr for the 99355
Total face to face physician time = 4.75 hours
60 for the 96365
60 for the 96366
Total infusion time = 2 hours
Total patient time in office receiving treatment or service is 6.75 hours
Also you cannot charge the 36000 with the infusion codes.
It just seems like a lot of physician time for pain management. It also looks as though you can have only two patient a day on average if this is your average patient.
 
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