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Prolonged Service Codes

  1. #1
    Default Prolonged Service Codes
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    Urgent help needed for my providers understanding for the use of prolonged service codes.

    My understanding is that they are to be used when a provider exceeds the time for the E/M visit and they are still with the patient providing face to face service over 30 minutes during the same session.

    They want me to define what same session means, because they think, that if they see a pt for DM in the morning and spend 25 minutes with that patient face to face, then in the evening they are called to see the patient because the patient fell due to gait instability and they spend an additional 35 minutes with the patient that the second interaction, qualifies them to use the prolonged service code 99356 because they added the two visits time together.

    They are looking at 'same session' as all time spent for that day with the patient.

    I am saying 'same session' is per encounter for the same presenting problem that may have worsened during the day and the provider came back to re-evaluate and treat the patient, which resulted in additional time over and above the first E/M level that constitutes the use of prolonged service code.

    Can my faternity give me guidance please?


    Quote: Freedom is not worth having if it does not include the freedom to make mistakes. ~Gandhi

  2. #2
    See this from CMS's IOM-04, Chapter 12, Section (page 80 of the PDF) addressing prolonged care:

    C. Requirement for Physician Presence
    Physicians may count only the duration of direct face-to-face contact between the physician and the patient (whether the service was continuous or not) beyond the typical/average time of the visit code billed to determine whether prolonged services can be billed and to determine the prolonged services codes that are allowable.

    The phrase "(whether the service was continuous or not)" implies you may aggregate the total time in a day.
    Jenny Berkshire, CPC, CEMC, CGIC

  3. #3
    Yes I understand that, however they state for the same session. what do you take that phrase to mean? CPT 2010, page#28, Prolonged Service Codes, first paragraph

  4. #4
    See the referenced "CPT Assistant," June, 2008 page 12. There is a whole page of coding clarification for prolonged care. It states, "These services are for prolonged services on a given date. The primary service and the prolonged services must occur on the same date. The time standards for reporting prolonged services require that the services occur on one date."

    You can get copies of "CPT Assistant" from the AMA if you don't subscribe.
    Jenny Berkshire, CPC, CEMC, CGIC

  5. #5
    Just an update on Jenny's post, in 2010 CPT, clarification was made to the prolonged service codes that the services do not have to be on the same date. The key to using prolonged services is that it is all related to the initial E/M service and that such service does not need to be continuous.


  6. #6
    Hi again! Sorry, meant to add this to my prior post! You can find the answer you're looking for in the Medicare Claims Processing Manual, Chapter 12, Section 30.6.7.B:

    30.6.7 - Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99201 - 99215)
    (Rev. 731, Issued: 10-28-05, Effective: 01-01-04 Chemotherapy and Non-Chemotherapy drug infusion codes/01-01-05 Therapeutic and Diagnostic injection codes, Implementation: 01-03-06)

    B Office/Outpatient E/M Visits Provided on Same Day for Unrelated Problems
    As for all other E/M services except where specifically noted, carriers may not pay two E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office or outpatient setting which could not be provided during the same encounter (e.g., office visit for blood pressure medication evaluation, followed five hours later by a visit for evaluation of leg pain following an accident). (emphasis added).

    So your scenario where the patient was seen in the morning for one condition and again in the afternoon for another condition would be reported using 2 E/M codes, not 1 E/M code and the prolonged service code.


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