EM Coding Alert

Precise reasons in the note for extra time spent on a service are key to getting payment.

When your provider spends a prolonged amount of time with a patient, which prevents her from earning revenue by seeing other patients, you may be able to help her get some additional money. You need the medical record details to point you to the needed add-on codes.

Seeing how other specialties handle the situations may help you handle yours. Review these three scenarios and pick up tips on what your doctor’s records should include before you report outpatient prolonged service codes.

Separate the F2F from the Non-F2F Time

When your provider performs prolonged services in the office or another outpatient location you’ll have four codes to choose from. You’ll look at the time spent and the type of service to select the final code.

You’ll use the following pair of E/M prolonged service codes on claims to report all face-to-face (F2F) time your provider spends with a patient on the same date of service:

• 99354 — Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour
• +99355 — … each additional 30 minutes.

You’ll use this other pair of E/M prolonged service codes on claims to report all of the physician non-face-to-face time for a patient on the same date of service:

•  99358 — Prolonged evaluation and management service before and/or after direct patient care; first hour
•  +99359 — … each additional 30 minutes.

Key point: The time involved with either code does not have to be consecutive, but it does have to be on the same day.

Reminder: Prolonged service codes are add-on codes, which are services performed in addition to the primary service by the same physician.

Time is a crucial piece of the note that you rely on for coding prolonged E/M services. Here are three scenarios from three different specialties that explain when and how you can report prolonged services.

Gastroenterology: Track the Time

Scenario: Your gastroenterologist sees an established patient that presents with nausea, vomiting, and abdominal pain. He spends 100 minutes on the E/M service. He performs a detailed history, a detailed examination, and medical decision making (MDM) of moderate complexity. During the encounter, the physician administers a dose ofintramuscular Phenergan. Over the next hour, he watches the patient for signs of improvement. He examines the abdomen several times during the hour

Code it: You will code the procedure with 99214 (Office or other outpatient visit for 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) since the gastroenterologist performed a detailed history, detailed exam, and moderate complexity MDM. Additionally, you will report +99354.

Coding explanation: The typical time spent on 99214 is 25 minutes. Doing the math, subtract the typical time spent (25) from the actual time spent (100), giving you 75 minutes. Therefore, you will report the first 60 minutes of the 75 with +99354. Because the remaining time does not exceed the 15 minute threshold, you do not include +99355.

Expert feedback: “Prolonged service codes would not be reported for anything under 30 minutes (above the average time of the normal service),” says Jacqueline Mehalich, RN, CPC, CPC-H, manager of physician education at Allegheny Health Network in Pittsburgh, Pa. “In addition, the add-on codes for additional 30 minutes (+99355/+99357) should not be reported for anything that  does not extend past the next 15 minutes.”

Family Practice: Nail Down In-Office Use

Scenario: A new patient comes into your practice and one of your physicians spends 140 minutes evaluating the patient. She performs a comprehensive history and examination and an MDM of high complexity. Most of the time is spent counseling and on the coordination of care.

Code it: You will submit procedure code 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination;medical decision making of high complexity) because your physician performed a comprehensive history, comprehensive exam, and high complexity MDM. You will also report +99354 and +99355.

Coding explanation: Based on the three key components and the 99205 code requirements, you report 99205, which typically take 60 minutes. Subtract the typical time spent on the E/M (60) from the actual time spent (140), to get 80 minutes. Therefore, the prolonged service is 80 minutes, which exceeds the 30-minute threshold that your physician must cross so you can report +99354. Since the prolonged service exceeds the typical time for +99354 (60) by 20 minutes, you will also report +99355.

Remember: You can only report one unit of +99354 per date of service. You can report multiple units per day of +99355 with +99354.

Pediatric: Highlight Non-F2F Time

Scenario: Your pediatrician sees a new patient who recently left the neonatal intensive care unit (NICU). The child has Down syndrome and ventricular septal defect leading to congestive heart failure. Your doctor spends 40 minutes reviewing the patient’s detailed medical records before she sees the child. She performs a comprehensive history and examination with MDM of high complexity that takes 50 minutes.

Code it: You will report 99205 for the F2F E/M encounter, since your doctor performed a comprehensive history, comprehensive exam, and high complexity MDM. Then include +99358 for the additional non-F2F time.

Coding explanation: Because the provider spent 40 minutes of extended non-F2F time on this patient, which falls within the 60-minute threshold for prolonged service coding, you report +99358. Justifying the extended non-F2F time in the medical record is vital your claim’s success. Every task mentioned in the note needs to have a time assigned and every person the physician spoke to about the case while away from the patient needs to be recorded in the record.

Expert insight: “The note should clearly reflect information explaining why the service was extended,” says Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, director of coding operations at Allegheny Health Network in Pittsburgh, Pa. “In this example, the patient’s co-morbid conditions and the medical history should be noted to justify the additional code for the additionaldecision-making needed.”

There is a catch: Be sure to look at your payer’s policy on +99358 and +99359. If there is no face-to-face contact, some payers will deny the claim.