Anesthesia Coding Alert

CPT gives new instructions to go straight to 99354-99359.

If you've tried adding modifier 21 onto a 99245 or 99223 service that took longer than usual, it's time to celebrate. CPT 2009 eliminates this pitfall by directing you to prolonged services codes with no modifier anymore.

Providers and billers can sometimes forget that CPT allowed modifier 21 (Prolonged evaluation and management services) only for the highest level E/M code in a category, says Lynn A. Brown, CPC, director of physician coding and reimbursement at Children's Health System in Birmingham, Ala. Per CPT 2008, Appendix A, you would use modifier 21 only with "the highest level of E/M service within a given category" and only on an E/M code.

"If the time documented did not exceed 30 minutes above the CPT allotted time," you could possibly append modifier 21 to the E/M, Brown explains. "Because modifier 21 was redundant in some cases and confusing to some, eliminating this modifier will simplify the decision," she says.

Using a code in the range between 99354 to 99359 (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] . . .) rather than modifier 21 gives you a more quantified description with established RVUs.

Previously, carriers had to determine how much, if any, additional payment to allow for use of modifier 21. "The prolonged E/M service codes clarify whether it was face-to-face time with the patient and specify exactly the time parameters involved," explains Jennifer Swindle, RHIT, CCS-P, CPC-EM-FP, CCP, director of coding compliance/charge entry for QLIMG, and director of the coding and compliance division of PivotHealth LLC in Garden City, N.Y.

You should code the level of care based on medical necessity and time. Report E/M services 30 minutes beyond the usual service for direct and indirect patient care using prolonged services codes in the range of 99354 to 99359.

Example: A visit, in which the E/M medical necessity level meets the criteria 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), takes 60 minutes. This visit would be eligible for an additional prolonged service code of 99354 (Prolonged physician service . . .; first hour) with 99214, Brown says.

2008 method: In the office setting, you could have used modifier 21 on only 99215 (Office or other outpatient visit for the evaluation and management of an established patient . . .), not 99214, but the visit's medical necessity might not have warranted reporting this level of care.

If you were one of the lucky coders obtaining reimbursement for 99215-21, CPT 2009 will likely be a disappointment. Come January, you will no longer report prolonged service of less than 30 minutes total on a given date separately because the work involved is included in the total work of the E/M codes, according to new CPT notes for 99354 and 99356.

Loss of payment on soon-to-be-included prolonged services, however, will probably not be widespread. Many payers do not recognize modifier 21 for additional payment, Brown notes.

Expect an easier time getting paid for prolonged services that a physician provides face-to-face with a patient. Most payers recognize prolonged services codes for direct patient care, but not for indirect or non-face-to-face care, Brown says.