Recoup Pay for Lengthy Asthma Visits

Here's what you need to know to bill 99354

If you want to charge 99354 when your allergist treats asthmatic reactions, think again. Unless the allergist spends 30 minutes past the E/M-defined time, reporting 99354 is overbilling.
 
You may think that prolonged services start with 30 minutes. But to use +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service ...; first hour ...), your allergist has to provide a half-hour of face-to-face time with the patient beyond the usual time specified in the E/M code.

Failing to follow CPT's time parameters could cause you to overbill or underbill your allergist's time. So make sure you're not opening the door to an audit by coding the following example: An allergist sees a 10-year-old boy for an asthma attack on an emergency basis. She spends 30 minutes with the child and leaves the room. The nurse nebulizes him (94640). Then the physician returns for two minutes and listens to his lungs following the nebulizer treatment. The physician wants to bill 99214 and 99354 for her time. Is this appropriate?
Bill 99214, 99354 When Allergist Spends 55 Minutes
In this case, because the physician spent only seven minutes over the usual time for 99214 (Office or other outpatient visit for the evaluation and management of an established patient ... physicians typically spend 25 minutes face-to-face with the patient and/or family), a prolonged service code (99354, +99355 ... each additional 30 minutes [list separately in addition to code for prolonged physician service]) does not apply, says Jaime Darling, CPC, certified coder for a nine-physician practice in Escondido, Calif.
 
CPT guidelines stipulate that you should not use prolonged service codes for services lasting less than 30 minutes beyond the usual service, Darling says. So, you should report only the office visit code (99214) for the E/M service. To report 99354, the allergist would have to spend an additional 30 minutes past the time designated in the office visit code. CPT provides 25 minutes for 99214.
 
Thus, you may report 99354 (30 minutes) with 99214 (25 minutes) when the allergist spends a total of 55 face-to-face minutes with a patient on the same date of service, Darling says. "According to CPT guidelines, the time does not have to be continuous. But it does need to be on the same date as the original E/M service," she adds. In the asthma example, the allergist spends a total face-to-face time of 32 minutes treating the patient, rather than the necessary 55. In this case, the visit does not qualify for 99214 and 99354.
Modifier -21 Applies to 99215, Not 99214
 After billing 99214, you [...]

- Published on 2003-09-15