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Prolonged services vs billing est. pt visits (99211 - 99215)

  1. #1
    Default Prolonged services vs billing est. pt visits (99211 - 99215)
    Clearnace Sale
    We now have an APRN with our practice who will be teaching our patients how to self-inject Cimzia for treatment of Crohns. She typically spends 60 minutes with the patients, and over 50 % of the visit is spent in counseling the patients on how to use the Cimzia. (actually close to 100% of the visit time is spent in couseling/teaching the patients)

    Would it be appropriate to bill a 99215 for these visits? Another practice mentioned that they code the visit based on the history, exam and MDM, for instance as a 99213, and then use the prolonged services codes to bill for the additional time spent counseling/teaching the patients. (99354, 99355)

    How would you code for this type of visit? 99215 or 99213, 99354? Why?
    Last edited by Colliemom; 03-16-2010 at 01:14 PM.

  2. #2
    Has anyone had a similar situation come up in their office?

  3. #3
    Hi -
    Since the visit is primarily counseling I would use the time rule and bill the appropriate code. In case of a 60 minute visit with nearly 100% of the time spent in counseling a 99215 is correct. It would be wrong to bill based on the elements if the visit is so obviously time driven and it would leave the impression that the visit is coded by the elements in order to utilize the prolonged services codes. If the visit, however, takes more than 30 minutes longer than 40 minutes (typical time for 99215), e.g., 75 minutes, then it would be appropriate to claim 99215 plus 99354 (in the office setting with an established patient and the appropriate documentation, of course!)
    Karolina, CPC, CPMA, CEMC

  4. #4
    Tuscaloosa, AL
    From CPT "when counseling/coordination dominates the PHYSICIAN/patient encounter. . ., then time may be considered the key factor". I don't know about APRN or CRNP billing specifically, but I would think that you could NOT bill this out under your physician (and you may not intend to do this). I am interested in knowing other opinions.

    Jerri, CPC

  5. #5
    Jerri - you make a good point, no where does it mention physician and/or NPP. We would not bill these visits under the physician, only the APRN. So I would also be curious to hear what other coders think would be the appropriate way to code for these visits.

    Karolina, thank you, I agree with you. I just wasn't sure that billing using the prolonged services codes for a 60 minute visit was appropriate under the circumstances I described. I guess the only question left, is can we bill for the APRN based on time.
    Last edited by Colliemom; 03-17-2010 at 09:40 AM.

  6. #6
    Milwaukee WI
    Default Allied health professionals
    Allied health professional (PAs, NPs, etc) MAY use time as the determining factor in selecting the code when more than 50% of the total face-to-face time was spent in counseling/coordination of care.

    F Tessa Bartels, CPC, CEMC

  7. #7
    Thanks Tessa that was my understanding as well. Do you agree with Karolina that it would be correct to bill the 99215, unless the time exceeds 75 minutes? (in which case we could bill the 99215 and the 99354)

  8. #8
    White Plains, NY
    Why would this not be 98960: Education and training for patient self management by a qualified non-physician health care professional using a standardized curriculum, face to face with the patient each 30 minutes.

    Lin CPC

  9. #9
    We contacted our Medicare carrier and that code, 98960, is not on their fee schedule. We also contacted BCBS and they said they do not pay for that code either.

  10. #10
    White Plains, NY
    That's interesting. I work for a payer and we do!

    Lin CPC

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