EM Coding Alert

Make sure your prolonged services pass the half-hour mark.

Have you ever wondered about your reporting options when your physician provides prolonged service(s) for a patient beyond the usual evaluation and management (E/M) service time?

For prolonged services with direct patient contact, you will choose from the +99354 (Prolonged evaluation and management or psychotherapy service[s] [beyond the typical service time of the primary procedure] in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service])  through +99357 (Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; each additional 30 minutes [List separately in addition to code for prolonged service]) code range.

Recently the Centers for Medicare and Medicaid Services (CMS) announced big news regarding the codes for prolonged services without direct patient contact - 99358 and +99359 (Prolonged evaluation and management service before and/or after direct patient care ...)

Background:

Previously, 99358 and +99359 were bundled under +99354-+99357. But, effective as of Jan. 1, 2017, 99358 and +99359 will be separately payable, according to CMS transmittal #R3678CP and #CR99358.

Don't leave money on the table! Read on to discover your prolonged service reporting options.

Answer Direct Contact Question Before Coding

Remember, to report a prolonged service code, your documentation must support the medical necessity for services that extend beyond the usual E/M service time.

"Coders have to be careful of 'double dipping' and reporting the same amount of time under two codes," says Laureen Jandroep, CPC, COC, CPC-I, CPPM, founder/CEO Certification Coaching Organization, LLC in Oceanville, N.J. "Prolonged services are for time reported beyond the time spent on any other service reimbursable under the Medicare Fee Schedule."

Your options for prolonged services are:

A. Prolonged Service with Direct Patient Contact

• +99354, Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service)
• +99355, ...; each additional 30 minutes (List separately in addition to code for prolonged service)
• +99356, Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient Evaluation and Management service)
• +99357, ...; each additional 30 minutes (List separately in addition to code for prolonged service).

You can also break the +99354-+99357 codes out into further categories.

How? "Codes 99354-99355 are used only in the outpatient setting, but apply to a regular E/M service when a patient presents with a problem or when the prolonged service is required during a psychotherapy session," says Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, N.M. "These codes require direct face-to-face interaction with the patient."

On the other hand, with 99356-99357, the prolonged service time is based on unit/floor time devoted to the care of the inpatient.

"99356-99357 only apply to situations where the patient has been admitted to the hospital, or has been admitted to observation status," says Witt.

B. Prolonged Service without Direct Patient Contact

• 99358, Prolonged evaluation and management service before and/or after direct patient care; first hour
• +99359, ...; each additional 30 minutes (List separately in addition to code for prolonged service.

You would use 99358 or 99359 when the physician provides a prolonged service that is considered neither face-to-face time in the office or outpatient setting, nor additional unit/floor time in the hospital or nursing facility setting during the same session of the E/M service.

Remember, in this case, the prolonged service must relate to the E/M service for a patient where direct face-to-face care has already occurred or will occur and also relate to ongoing patient management.

According to CMS's Final Rule, allowing separate payment for 99358 and 99359 will "provide a means to recognize the additional resource costs of physicians and other billing practitioners when they spend an extraordinary amount of time outside of an E/M visit performing work that is related to that visit and does not involve direct patient contact (such as extensive medical record review, review of diagnostic test results, or other ongoing care management work)."

The codes 99415 (Prolonged clinical staff service during an evaluation and management service in the office or outpatient setting direct patient contact with physician supervision; first hour...) and 99416 (... each additional 30 minutes) are available codes when the staff spends prolonged time with the patient. However, check with your payer first, as these codes may not qualify for reimbursement.

Understand The Importance of Time

Time is a key factor in determining whether to use a prolonged service code. Note, you cannot separately report a prolonged service that is less than 30 minutes' total duration on a given day.

Turn to 99354 or 99356 to report the first hour of prolonged service on a given date, dependent upon the place of service (POS). You can also use 99358 to report the first hour of prolonged service on a given date, but its use is not dependent upon the POS. You should use all three codes only once per day.

Look to 99355 or 99357 to report each additional 30 minutes beyond the first hour, dependent upon the POS. You can also use 99359 to report each additional 30 minutes beyond the first hour, but its use is not dependent on the POS. You may use all three codes to report the final 15-30 minutes of the prolonged service on a given day. You cannot separately report a prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes.

Apply Your Prolonged Services Coding Smarts

Look at this example from Witt: A 50-year-old female with a history of asthma (Z87.09 [Personal history of other diseases of the respiratory system]) presents with acute bronchospasm (J98.01) and moderate respiratory distress. The initial E/M shows respiratory rate of 35/min, labored breathing, and wheezing heard in all lung fields. The physician initiates office treatment, including intermittent bronchodilation and subcutaneous epinephrine. The patient requires intermittent physician face-to-face time to evaluate her response to treatment, and the physician lets her go home after 2 and a half hours. Note that the physician documents only 110 minutes of direct face-to-face time.

Application: The physician reports 99214 (Office or other outpatient visitfor the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity ...) for the E/M service (typical time 25 minutes). The physician documents the total face-to-face time with the patient as 110 minutes. As the provider must exceed the typical time of 25 minutes by 30 minutes, prolonged service billing time starts at 55 minutes. So, you can bill 55 minutes of prolonged services with 99354 for the first hour.