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Thread: billing question for denied 99245 and EXT service.

  1. #1
    Join Date
    Apr 2007
    Everett, WA

    Default billing question for denied 99245 and EXT service.

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    Followup procedures when E/M claim denied along with Prolonged Service Codes from an 08 claim? AR work reveals that a 99245 was rejected along with an extended service code of 99354. Lengthy review by insurance company said chart notes did not support the total charges for both codes. Upon reviewing the chart notes, I understand why the 99354 was denied, but NOT the 99245 It's clearly an indication of less than stellar documentation. However, (rookie question--How long can I use this excuse? ), Can we resubmit WITHOUT the prolonged service code and still get paid for the 99245? Doctor did have a long visit with the patient for C&C, but there is no actual documentation of time spent, only the issues discussed. Or do we let it stand and allow it to be written off, and write a note to the doc stating the reason---- that only if he had documented better with face-to-face timeline guidelines as furnished by CPT 2009 Professional Edition -p.26) his E/M visit could have been assigned a Prolonged Service Code? Surely, at least the 99245 visit would be considered, right?
    Is there additional information I need to furnish to get comments? ---Suzanne E. Byrum, CPC-A

  2. #2
    Join Date
    Apr 2007
    Seacoast- Dover New Hampshire


    I believe that when using time as a code, it needs to be listed in the note total time spent face to face.
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  3. #3
    Join Date
    Apr 2007
    East Stroudsburg, PA


    99245 only states that the physician TYPICALLY spends 80 minutes with the patient.

    My understanding is that this is just as a reference to give you as the coder an idea as to time spent with the patient. Even if the doctor states that he spent 80 minutes with the patient, his documentation needs to support the level of service (Comprehensive history, Comprehensive exam and Medical decision making of high complexity.) I would resubmit the 99245 or appeal it as long as there is still time for the appeal.
    ~Rebecca, CPC, COSC, CPC-I

    "To the world you may be one person, but to one person you may be the world" ~Anonymous

  4. #4


    Hi, this info from Medicare might help:

    go to www.cms.hhs.gov
    Regs & Guidance
    click on the "Medicare Claims Processing Manual"
    go to 30.6.15 or page.79

    worth a try anyway!

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