Gastroenterology Coding Alert

CPT®2012 opens opportunity of using code by every specialty.

When your gastroenterologist sees a patient for a condition such as protracted vomiting (ICD-9 code 787.03) requiring in-office medication and observation or obstipation/ impaction (564.09, 560.3) requiring in-office enema or disimpaction, you may be able to report prolonged services codes +99354 and +99355 to capture the time and work. The good news is that a 2012 CPT® revision allows you even more bandwidth in using these codes. Read on for advice on accurate reporting with this change.

Expand Office or Outpatient Prolonged Services

In 2012, you'll have more flexibility in applying office or outpatient prolonged services code +99354, thanks to this provider-related revision:

Old way: +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].

New way: +99354 (Prolonged service 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 service]).

Big change in 2012: The new descriptor eliminates the words "physician" and "face-to-face", which broadens the scope for reporting prolonged services. The descriptor is now suitable for use by a wider range of providers and is not restrictive for face-to-face physician services rendered in an outpatient or office setting. "For instance, physician assistants and nurse practitioners often work in conjunction with physicians and can deliver care to patients seen urgently as work-in office visits," says Michael Weinstein, MD, Gastroenterologist at Capital Digestive Care in Washington, D.C., and former representative of the AMA's CPT® Advisory Panel. "A patient needing prolonged services might initially see the physician to determine a plan of care and then the PA or NP will continue to monitor the patient and adjust therapy as needed."

Similarly, the additional 30-minute codes follow the same revision eliminating face-to-face physician time.

New way: For every additional 30 minutes of prolonged services, you'll report +99355 (Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes [List separately in addition to code for prolonged service])

Old way: + 99355 in 2011 was Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service;  each additional 30 minutes [List separately in addition to code for prolonged physician service].

Append to Appropriate E/M Codes

You should remember that prolonged services are add-on codes that you have to report with appropriate evaluation and management codes. You can report prolonged services when your gastroenterologist spends a total of 30 minutes beyond the typical times (as mentioned in the CPT® guidelines) for a particular E/M code.

"When the level of service of a particular code is met, however, the time involved with the patient exceeds the highest level of that code grouping, you would use the prolonged service codes," says Suzan Berman, CPC, CEMC, CEDC, Senior Director of Physician Services -Health Revenue Assurance Associates, Plantation, Florida.You will report prolonged services in the outpatient setting or office with +99354. You can report every additional 30 minutes of direct patient contact with +99355.

Remember: You can report prolonged service codes with E/M codes 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient...) depending on the level of evaluation and management.

"Checking with your local payers is important before reporting these as with any service - just because there is a code doesn't mean it will be reimbursable," says Berman. "Just as with any other E/M service, the first code chosen should only be billed once per calendar day."

You cannot report prolonged service codes +99354 and +99355 if you are reporting 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services).

Example: Your gastroenterologist spends a hundred minutes to complete a level four E/M service and initiates treatment of an established patient presenting with nausea, vomiting, and abdominal pain. After obtaining a complete history and performing a comprehensive physical exam, the physician administers a dose of intramuscular Phenergan and observes the patient for improvement over the next hour repeating the abdominal exam at intervals.

You should report 99214 (Office or other outpatient visit for the evaluation and management of an established patient...), +99354 and +99355. The typical time for 99214 as per CPT® guidelines is 25 minutes. Since your gastroenterologist spent 75 minutes more than the typical time, you should report the first thirty minutes with +99354 and +99355 for the remaining time.

Capture Reason for Prolonged Services

"The documentation should certainly substantiate the E/M level of service being billed," says Berman. "The documentation would then further describe why the extra time was spent with the patient (unusual examination issues, detailed history retrieval for medical decision-making, discussion of treatment plan, test results, etc). The document should be robust enough to clearly illustrate why the lengthy service was done and needed."

"The time the physician spends with the patient does not have to be continuous," reminds Berman. "The time would be added up throughout the visit and then billed out accordingly."

Example: Your gastroenterologist performs a level two E/M for a patient with swallowing difficulty beginning earlier in the day. Upon assessment of the patient, he decides to send the patient for a diagnostic barium esophagram test. The total time spent during this session is 25 minutes. The patient goes for the test and comes back to your gastroenterologist later in the day to discuss the test results. Your gastroenterologist spends another 20 minutes during this session.

Here, you add the time spent in both the sessions to assess whether or not you need to prolonged services. Since 40 minutes is the typical time spent for a level five E/M visit and more than half the time in this case was spent in counseling / coordination of care, you do not need to report a prolonged service code but can instead report 99215.

Example: Your gastroenterologist completes a level four E/M in 75 minutes including a review of extensive prior tests and two years of treatment records brought by the patient for review and explanation. The typical time for a level four E/M is 25 minutes. Since your gastroenterologist spent extra 50 minutes beyond the stipulated time for level four E/M, you should report 99214 for the first 25 minutes and +99354 for the extra 50 minutes.

Remember: If the time spent by your gastroenterologist is more than the threshold time to report +99354 but is lesser than threshold time required to report +99355, then you should only report the E/M code with +99354.