Gastroenterology Coding Alert

Learn what codes to use both in an inpatient and outpatient setting

Reporting prolonged services may be complicated, but you could be missing out on extra reimbursement if you don't tackle modifier 21 and prolonged services codes.
 
Be forewarned: -Payment may be problematic,- says Deanna L. Sherland, CPC, billing supervisor for Southern Illinois Physicians Services in Belleville. Follow these rules, and you-ll know when each is appropriate.

Grasp These Prolonged Care Concepts

Rule 1: When the time spent on an E/M service is less than 30 minutes past the typical time for the highest E/M code in a family (for office or other outpatient services 99205 and 99215; for hospital inpatient services 99223 and 99233), you may use modifier 21 (Prolonged evaluation and management services) on the E/M code.
 
Example: If the gastroenterologist provides prolonged E/M services for a new patient 19 minutes past the typical time, you would append modifier 21 only to new patient code 99205 (Office or other outpatient visit for the evaluation and management of a new patient, comprehensive history; a comprehensive examination; and medical decision-making of high complexity). You cannot append modifier 21 to 99201 through 99204 because they are not the highest level.
 
Rule 2: Use prolonged services in addition to the E/M service code when care is 30 minutes or more beyond the usual service of a time-based code. The time does not need to be continuous. -A physician can spend 10 minutes with the patient, go away and come back later,- says Quinten A. Buechner, MS, MDiv, ACS-FP/GI/PEDS, CPC, CCP, CMSCS, president of ProActive Consultants LLC in Cumberland, Wis.
 
Example: The gastroenterologist sees an established patient and spends an extra 45 minutes in addition to a 99215 service. For this visit, you should report +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour [list separately in addition to code for office or other outpatient evaluation and management service]) as well as 99215.
 
Rule 3: Count the cumulative time you spend providing that patient either direct (face-to-face) or without direct services on that given date (+99358, Prolonged evaluation and management service before and/or after direct [face-to-face] patient care [e.g., review of extensive records and tests, communication with other professionals and/or the patient/family]; first hour; and +99359, ... each additional 30 minutes).
 
In other words: Before or after face-to-face services may include:

 - review of records
 - test results
 - communication with other health professionals or family including phone time.

Rule 4: Choose the direct prolonged service code based on the site of service.
 
For outpatients 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 (list separately in addition to code for office or other outpatient evaluation and management service)

- +99355 -- ... each additional 30 minutes (list separately in addition to code for prolonged physician service). 

Inpatient codes include:

- +99356 -- Prolonged physician service in the inpatient setting requiring direct (face-to-face) patient contact 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 physician service).

 
Rule 5: Use the direct-care time minus the time built into the E/M service reported to assign the correct code combination as in the chart shown.