Allergy Coding Alert
Reader Question: Prolonged Services
Question: What are the requirements for reporting prolonged service codes 99354 and 99355?
Washington Subscriber
Answer: According to CPT, 99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient evaluation and management service]) and 99355 ( each additional 30 minutes [list separately in addition to code for prolonged physician service]) describe face-to-face, physician-to-patient contact that is beyond the usual service in either the inpatient or outpatient service. Prolonged services may be billable, for instance, if a patient requires nebulizer treatment and the physician must spend a lot of time with him or her, or for a difficult or noncompliant patient who requires additional time to diagnose, treat or otherwise attend to.
Prolonged services are reported in addition to other physician services, including E/M services at any level. Because 99354-99355 are time-based they may only be appended to codes that include a reference time. Specifically, Section 15511.1 of the Medicare Carriers Manual (MCM) dictates that 99354-99355 may only be reported in addition to 99201-99205 and 99212-99215 (Office or other outpatient visit) or 99241-99245 (Office or other outpatient consultation).
To report the first hour of prolonged services, you must exceed the reference time for the primary E/M service (found in the CPT code descriptor) by a minimum of 30 minutes. For example, the allergist provides an E/M service that measured by the key components of history, examination and medical decision-making qualifies as a level-two outpatient visit (99213). Because the physician spends time discussing treatment options with the patient, however, the visit requires 57 minutes 42 minutes beyond the 15 minutes allotted (per CPT guidelines) for a level-three established patient office visit. In this case, because the services provided were beyond those typically provided (i.e., requiring 42 minutes longer than usual), the physician may report 99213 and 99354.
To report an additional half-hour of prolonged services, the total time required beyond the reference time of the primary E/M code must equal at least 75 minutes. The physician must account for at least 15 minutes of every additional half-hour billed. In the above example, if the visit lasted a total of 95 minutes the physician would report 99213, 99354 and 99355 (95 minutes - 15 minutes reference time = 80 minutes, or one hour and 20 minutes of prolonged services). If the total visit had lasted only 85 minutes, the additional half-hour is not allowable (85 minutes - 15 minutes reference time = 70 minutes, or only 10 minutes not the required 15 minutes beyond the first hour).
If warranted, physicians may report multiple units of 99355 or 99357 (... each additional 30 minutes [list separately in addition to code for prolonged service]). Again, using the above example, a two-hour visit would be reported: 99213, 99354, 99355 x 2 (120 minutes - 15 minutes reference time = 105 minutes, or one hour plus 30 minutes plus 15 minutes).
Note: A complete list of threshold times for reporting prolonged services with individual E/M services is found in the MCM, Section 15511.1, subsections E and F.
Time counted toward prolonged services must occur on the same date of service but need not be continuous. To count effectively, however, all time must be appropriately documented. The MCM, section 15511.1, instructs carriers to Advise physicians that to support billing for prolonged services, the medical record must document the duration and content of the evaluation and management code billed... Therefore, simply noting that an extra 42 minutes were spent with the patient is not adequate: The extra time must be explained and justified.
Prolonged services must be provided face-to-face (and they must be documented as such). Unlike the care plan oversight codes, prolonged services do not apply if the allergist spends time arranging treatment in the patients absence or discussing a patients condition with other healthcare professionals. Even if a patient spends four hours in the physicians office, but the physician sees the patient face-to-face for only 20 minutes, prolonged services are not billable.
Washington Subscriber
Answer: According to CPT, 99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient evaluation and management service]) and 99355 ( each additional 30 minutes [list separately in addition to code for prolonged physician service]) describe face-to-face, physician-to-patient contact that is beyond the usual service in either the inpatient or outpatient service. Prolonged services may be billable, for instance, if a patient requires nebulizer treatment and the physician must spend a lot of time with him or her, or for a difficult or noncompliant patient who requires additional time to diagnose, treat or otherwise attend to.
Prolonged services are reported in addition to other physician services, including E/M services at any level. Because 99354-99355 are time-based they may only be appended to codes that include a reference time. Specifically, Section 15511.1 of the Medicare Carriers Manual (MCM) dictates that 99354-99355 may only be reported in addition to 99201-99205 and 99212-99215 (Office or other outpatient visit) or 99241-99245 (Office or other outpatient consultation).
To report the first hour of prolonged services, you must exceed the reference time for the primary E/M service (found in the CPT code descriptor) by a minimum of 30 minutes. For example, the allergist provides an E/M service that measured by the key components of history, examination and medical decision-making qualifies as a level-two outpatient visit (99213). Because the physician spends time discussing treatment options with the patient, however, the visit requires 57 minutes 42 minutes beyond the 15 minutes allotted (per CPT guidelines) for a level-three established patient office visit. In this case, because the services provided were beyond those typically provided (i.e., requiring 42 minutes longer than usual), the physician may report 99213 and 99354.
To report an additional half-hour of prolonged services, the total time required beyond the reference time of the primary E/M code must equal at least 75 minutes. The physician must account for at least 15 minutes of every additional half-hour billed. In the above example, if the visit lasted a total of 95 minutes the physician would report 99213, 99354 and 99355 (95 minutes - 15 minutes reference time = 80 minutes, or one hour and 20 minutes of prolonged services). If the total visit had lasted only 85 minutes, the additional half-hour is not allowable (85 minutes - 15 minutes reference time = 70 minutes, or only 10 minutes not the required 15 minutes beyond the first hour).
If warranted, physicians may report multiple units of 99355 or 99357 (... each additional 30 minutes [list separately in addition to code for prolonged service]). Again, using the above example, a two-hour visit would be reported: 99213, 99354, 99355 x 2 (120 minutes - 15 minutes reference time = 105 minutes, or one hour plus 30 minutes plus 15 minutes).
Note: A complete list of threshold times for reporting prolonged services with individual E/M services is found in the MCM, Section 15511.1, subsections E and F.
Time counted toward prolonged services must occur on the same date of service but need not be continuous. To count effectively, however, all time must be appropriately documented. The MCM, section 15511.1, instructs carriers to Advise physicians that to support billing for prolonged services, the medical record must document the duration and content of the evaluation and management code billed... Therefore, simply noting that an extra 42 minutes were spent with the patient is not adequate: The extra time must be explained and justified.
Prolonged services must be provided face-to-face (and they must be documented as such). Unlike the care plan oversight codes, prolonged services do not apply if the allergist spends time arranging treatment in the patients absence or discussing a patients condition with other healthcare professionals. Even if a patient spends four hours in the physicians office, but the physician sees the patient face-to-face for only 20 minutes, prolonged services are not billable.
- Published on 2002-03-01
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