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Billing prolonged services

  1. #1
    Default Billing prolonged services
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    A friend of mine went to a dr and she was billed 99214+99354.

    How can they bill a prolonged service when they havent even used the highest level of em(99215) first?

    My way of thinking is they would have to first code the 99215 and then if it was atleast 30 minutes beyond the time of the 99215 code, then bill the prolonged.

    Am I wrong??? CPT assistant seems to support my thoughts as well.

  2. #2
    Evansville Indiana
    Default prolonged services
    According to the CPT guidelines, pg 28 "this service is reported in addition to other physician services, including evaluation and management services AT ANY LEVEL." If the documentation for the exam and medical decision making was appropriate for a level 3, but the time that was spent went well over the normal time for that level(and this was documented) then this billing would be appropriate. However, CMS is conducting a pre-payment review on ALL prolonged visit encounters and is generally denying them. There must be documentation of the time for the original E/M level and then additional documentation of time for the prolonged visit code. They are requesting all supporting documentation. They will review both the medical necessity of the original E/M code and the medical necessity of the prolonged visit. This could result in denial of the prolonged visit along with a reduction of the original level if documentation is not supporting.
    Hope this helps.

  3. #3
    Duluth, Minnesota
    I agree with cheermom - the 99354 can be used in conjuction with 99201-99215 (and other codes) yes, I guess the provider "can" do that ...HOWEVER - it does state "prolonged physician service in the office or other outpatient setting requiring DIRECT (face-to-face) patient contact beyond the usual service....

    soooooo... did the provider provide an additional 30-74 minutes of face to face contact/service with your friend? (above the supported level of 99214).. if not, I'd fight it, I wouldn't pay...
    Donna, CPC, CPC-H

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