EM Coding Alert

Question: We bill based on time pretty frequently, particularly when we see pediatric patients who have complex situations or require surgery. Their parents have a lot of questions and our gastroenterologist is really good about documenting time in the records. We have never used a prolonged service code because the different types are intimidating. What’s the difference between them?

Vermont Subscriber

Answer: E/M services that last longer than usual often means employing a prolonged services add-on code to describe the full extent of the service. But before you open up your CPT^®  code book, you need to make sure you know who provided the service and what they did.

When you are coding for prolonged services in an office/outpatient setting, you’ll choose from the following codes:

• +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)
• +99415 — Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour (List separately in addition to code for outpatient Evaluation and Management service)
• +99416 — … each additional 30 minutes (List separately in addition to code for prolonged service).

The difference between these two sets of codes for prolonged services would be who provided the service. Codes +99354 and +99355 are for prolonged services by a physician or other qualified health care provider — such as a nurse practitioner or physician assistant. Codes +99415-/+99416 are for clinical staff — such as a registered nurse [RN] or a licensed practical nurse [LPN]. One other difference is that +99354/+99355 include both prolonged E/M and psychotherapy, whereas +99415/+99416 only reference E/M.

You must report +99354 and +99355 for office/outpatient E/Ms that have a time component, and the typical time of the E/M service code billed must be exceeded by 30 minutes or more — the “first hour” descriptor term means the threshold to report the service is 50 percent or more of this time.

Also: The physician or advanced practice provider must be present to provide direct supervision of the clinical staff during +99415/+99416 encounters.

Remember, too, that +99354, +99355, +99415, and +99416 all require direct patient contact. For prolonged services that occur before or after direct patient care, you’d use 99358 (Prolonged evaluation and management service before and/or after direct patient care; first hour) and +99359 (… each additional 30 minutes [List separately in addition to code for prolonged service]). An example would be a prolonged review of outside medical records, imaging, etc. This can be reported for a different date than the E/M service it supports, but it cannot be reported to sum up increments of time spent on more than one date.