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



## Colliemom (Mar 16, 2010)

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?


----------



## Colliemom (Mar 17, 2010)

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


----------



## Karolina (Mar 17, 2010)

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!)


----------



## jthweatt (Mar 17, 2010)

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


----------



## Colliemom (Mar 17, 2010)

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.


----------



## FTessaBartels (Mar 17, 2010)

*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


----------



## Colliemom (Mar 17, 2010)

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)


----------



## losborn (Mar 17, 2010)

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


----------



## Colliemom (Mar 18, 2010)

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.


----------



## losborn (Mar 18, 2010)

That's interesting.  I work for a payer and we do!

Lin CPC


----------



## sammie06 (May 11, 2010)

If you have the documentation for the office visit 99214 and codes 99354 and 99354 where would you add the modifer 25


----------



## mitchellde (May 11, 2010)

the 98960 is a code for nonphysicians and nonpractitioners, you use that code for ancillary personnel such as the nurse.  I have not had any issue with Medicare or BCBS paying for that code.  When you have an office visit and a prolonged code you do not need the 25 as the 99354 is add on.  Also I have had reports from some states that APRN, PA and NPs are not allowed to use the prolonged time codes for their billing so FYI you might want to check on that first.


----------

