# please clarify - prolonged services



## coder32 (May 9, 2011)

For the original e/m visit, is it based off of medical necessity or time?  if a patient is seen for 80 minutes total.  do you bill a 99215 for the first 40 minutes with a prolonged services code for the additional time?


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## mitchellde (May 9, 2011)

prolonged time may be appended to any level of service.  you could have an 80 minute encounter for a 99213 if the 3 key components match that level and you would append a 99354 to the 99213.  It is based on both medical necessity and time spent face to face with the physician.


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## squallks (May 9, 2011)

Here is an answer from a WPS forum.  

Q6. How do we choose our procedure code when looking to also bill for prolonged care services? 
A6. Procedure codes are chosen in one of two ways; either based on the level of history, exam and medical decision-making or time when more than 50% of the face to face time is spent in counseling or coordination of care. When choosing the code based on history, exam, and medical decision-making, choose your code, and then look at the time associated with that code. The time associated with that level of service in addition to the threshold time for prolonged care services must be documented as face-to-face time in order to submit a prolonged care code. When choosing the code based on counseling/coordination of care, you must first meet the face-to-face time requirements for the highest level of service in that category and then meet the threshold time in order to use the prolonged care code.


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## coder32 (May 9, 2011)

*example*

below is example of documentation:  it was billed as 99215 but the physician wants it upcoded with a prolonged service code.

DISCUSSION:    This visit with XX and her husband took approximately an hour. It was predominantly a discussion, and we ranged over many topics. The majority of the visit was concerned with her severe dysmenorrhea and menorrhagia, and a discussion of what her options were for management, whether she should have surgery, etc. 

She has not tried any prescription strength nonsteroidal anti-inflammatories such as ibuprofen, Anaprox or Toradol. She has not tried Tramadol or any narcotics. I discussed the Lysteda which is new on the market, and she is not interested in trying something new, (and I didn't push it). It is not primarily the menorrhagia that is the problem, but the dysmenorrhea that comes along with that. 

What we did decide on was to have her start with ibuprofen 800 mg p.o. t.i.d. starting just before the worst day of her cycle (which she can predict since it is day 5), and if this works well, she should stay functional.

We also discussed that most of the really great management techniques medicinally for dysmenorrhea are hormonal, but she is not interested in any of the hormonal manipulations since they would interfere with her fertility. 

She had many questions about adenomyosis/endometriosis. I told her that her ultrasound is entirely reassuring. There was no evidence of any large areas of endometriosis nor any suspicion of adenomyosis. It was entirely normal. Her pelvic exam was also reassuring, and although I didn't tell her this specifically, the fact that she was nontender in the cul-de-sac and her uterus is nontender, while I distracted her with discussion, was reassuring to me. 

We discussed diagnostic laparoscopy. Generally speaking, this can give us information as to whether there are small implants of endometriosis in the pelvis which can be numerous, and for many years practitioners have cauterized these or lasered them, but the impact on improving fertility is minimal if present at all, and currently fertility specialists are even saying that endometriomas may not need to be addressed. Women with endometriosis have poor fertility, but it is not clear that by treating the endometriosis we can improve that. Therefore, it is a diagnostic test that is really quite expensive. At the time of a laparoscopy, a dye study can be done by squirting water soluble dye through the fallopian tubes to see if it comes out the fallopian tubes, but this is not a therapeutic procedure. A less expensive dye test is the hysterosalpingogram. I described this can be ordered in radiology, usually we prescribe doxycycline for three days starting the day of the procedure, and though it cannot billed under anything but fertility, it is certainly cheaper than doing it laparoscopically. (I basically told them that I would be richer if I spoke otherwise of the laparoscopy, but I feel better about being honest about it.) 

The patient wanted to know why she had cramps and some people don't and why they are severe, and I indicated that people are just different with different innervation and different sensitivities to the hormonal effects of pain such as prostaglandin. 

The patient then asked several questions about fertility, and we went over her husband's semen analysis (with him). He indicated that he has a specimen collection cup and will give another sample if we put in an order. They do not plan to do a hysterosalpingogram now.  She intends to work on losing weight so that she might have a healthier pregnancy. She apparently is checking ovulation indicators and is ovulating each month. 

When asked what could be done with his low sperm count, I said perhaps one or two days of artificial insemination each month could be performed, but otherwise in vitro fertilization with ICSI (I couldn't remember the acronym at the time but described injecting sperm nuclear genetic material into the egg) could be performed, and I quoted them a crude figure of $10,000 to $15,000 but with good success rates. I did indicate that genetic abnormalities are slightly higher but not dramatically so such as 2% increasing to 4% or 1.5% increasing to 3%. We did not go into that in great detail. 

Generally the patient indicated that they will have him get another semen analysis, when that comes they would prefer not to make another appointment but have the results transmitted via phone, and if there is no change recommended, they will pursue weight loss, making sure not to drink too much, continuing to have intercourse and perhaps will have an HSG done in the fall. 

If she has an HSG in the fall, then I recommended that she follow up thereafter, preferably with the fertility specialist that we hope to have on our staff at that point.


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## FTessaBartels (May 10, 2011)

*99215*

He doesn't have enough time documented to add any prolonged service. He would need at least 30 minutes BEYOND the 99215.  Since this is coded based on time spend in counseling/coordination of care and he spent a total of 60 minutes ...

40 minutes = 99215
20 minutes remaining ... no additional code

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## mitchellde (May 10, 2011)

I agree with Tessa.


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