Gastroenterology Coding Alert

The codes for prolonged services with direct patient contact (99354-99357) can be used to bill for E/M sessions that extend at least 30 minutes beyond the time limits established by CPT. An article in the July 2001 Gastroenterology Coding Alert, "Boost Level of Follow-Up E/M With Time as the Key Component," recommended that gastroenterologists use time as the key component when determining the level of a follow-up office visit when more than 50 percent of the session was spent in counseling and coordination of care. However, one reader, Barry Kisloff, MD, a gastroenterologist and director of Clinical Services and the Digestive Disorders Center at the University of Pittsburgh Medical Center, reports that his practice believes it is more appropriate to use the prolonged services codes to report E/M sessions when more than 30 minutes are spent in patient education and counseling.
 
"The gastroenterologist rendering largely counseling and/or education services during a patient encounter (in an office setting) may use the prolonged services codes in addition to the appropriate established office-visit code (99211-99215). The prolonged services codes seem clearly to be used for 'nonhands-on' services, which are so vital to the patient-physician relationship," Kisloff says.

E/M codes are designed to work with hands-on medicine, or office visits where the focus is on the traditional components of history, examination and medical decision-making, Kisloff says. "You examine the patient, then go through the systems and ask if he or she has any allergies or is taking any new medications. All discretely hands-on," he explains. "What has happened is that a large part of what any gastroenterologist does now is not hands-on. Patients have questions about the long-term effects of their medication, the natural history of their illness, or they bring in a family member who has questions for the doctor."
 
While gastroenterologists may be reporting more high-level E/M codes based on time, payers often look critically at these visits, says Kisloff, who feels that the prolonged service codes may be more compliance-oriented than an E/M code based on time as the key component. "If the patient's spouse walks in the room to talk about the interferon being given to treat the patient's hepatitis, and the gastroenterologist bills that session as 99214 ( ... physicians typically spend 25 minutes face-to-face with the patient and/or family) the payer is going to scrutinize that because the history, exam and medical decision-making may not justify that level of service," Kisloff explains.
 
"You then move into the arena of prolonged service codes," he continues. "The CPT definition for the code says 'beyond the usual service,' which is what patient education is about."
 
The prolonged service codes requiring direct patient contact are as follows:
 

99354 prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting); first hour (list separately in addition to code for office or other outpatient evaluation and management service)
 

99355 ... each additional 30 minutes
 

99356 prolonged physician service in the inpatient setting, requiring direct (face-to-face) patient contact beyond the usual service (e.g., maternal fetal monitoring for high risk delivery or other physiological monitoring, prolonged care of an acutely ill inpatient); first hour (list separately in  addition to code for inpatient evaluation and management service)
 

99357 ... each additional 30 minutes.

While CPT gives very limited examples of when to use these codes, the following situations are often cited by coding experts as reasons for using prolonged service codes:
 

The patient is noncompliant.
 

The patient has difficulty understanding the gastroenterologist due to mental handicaps, physical handicaps or language barriers.
 

The gastroenterologist has to explain complex treatment options, such as major surgery, to the patient.
 

The gastroenterologist has to explain lifestyle changes that patient must make, as in cases of hepatitis or cirrhosis.

Kisloff limits his use of the prolonged care codes to E/M sessions where patient education and counseling takes more than 30 minutes. In a non-educational situation, such as when the patient cannot speak English, Kisloff reverts back to time as the key component if the office visit is extended. "It is appropriate to upcode here because it took longer to do the standard elements," he says. "As long as I am gleaning information about the patient, I will appropriately upcode based on the amount of time expended. When I am no longer examining the patient or deriving information about the case, then the visit is purely educational and beyond the standard E/M service."
 
Some coding experts disagree with Kisloff and feel that it is entirely appropriate to bill prolonged services for non-educational situations. "If a patient is non-English-speaking, then everything takes longer the history, the examination, the counseling," says Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., a physician-practice management consulting firm in Spring Lake, N.J. "This is a perfect situation to use prolonged services codes because you can't use time as the key component since more than 50 percent of the session was not spent counseling and coordinating care."

Using a prolonged service code may also improve reimbursement. Let's say a gastroenterologist spends a total of 50 minutes with a patient and spouse. The history, examination and medical decision-making portion of the visit, which take about 15 minutes to perform, are at the level of a 99213 office visit. The remaining 35 minutes is spent discussing the patient's treatment options.
 
If the session is reported as a 50-minute E/M service where time is the key component, 99215 is billed. Reimbursement from Medicare will be about $117 on an unadjusted basis.
 
If prolonged services are billed instead, 99213 would be used to report the standard E/M portion of the session, and reimbursement would be about $50 on an unadjusted basis.
 
The prolonged services code 99354 would be used to report the 35 minutes spent on patient education. Medicare will pay an additional $118 for the prolonged services code, for a total reimbursement of $168.

While Kisloff has been using these codes for over 20 years, one problem with the prolonged service codes is that many payers do not recognize them. New Jersey Blue Cross Blue Shield, for example, is one that does not, Brink says.
 
Another reason why gastroenterologists shy away from using prolonged service codes is because they are complicated. "My practice never bills for them. It's hard enough for some gastroenterologists to understand the standard E/M codes," says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT advisory panel.
 
It may help gastroenterologists to keep the following points in mind when using prolonged services codes:
 
1. These are add-on codes. Prolonged service codes must be reported in conjunction with another E/M service code, such as an inpatient, outpatient, office visit or consultation. They cannot be used with emergency-room visits.
 
2. There's a 30-minute minimum. The prolonged service must last at least 30 minutes in order to be billable, and it must be in addition to the time spent on the standard portion of the E/M service. However, the time spent on the prolonged service does not have to be continuous.
 
Codes 99354 and 99356 are used to report the first 60 minutes of prolonged service. Code 99355 is used to report each additional 30 minutes of prolonged service after the first hour in an office setting or outpatient setting, and 99357 is used to report each additional 30 minutes of prolonged service in an inpatient setting.
 
If less than 30 minutes is spent on patient education, Kisloff doesn't bill for prolonged services or upcode the E/M service, which is reported on the basis of the history, examination and medical decision-making that occurred.
 
3. Non-face-to-face doesn't get paid. Although there are CPT codes for prolonged services without direct patient contact (99358 and 99359), Medicare has not assigned a relative value to those codes, which means it is unlikely that any Medicare carrier will pay for them. Most private payers don't recognize them either.
 
4. Time spent in prolonged service must be documented. This is a timed code, and gastroenterologists have to indicate the amount of time spent in prolonged services and what was done during that time. "Medicare does not say you need to list a stop or start time, but I recommend using those," Brink says. "You may not know going into the visit that it will be a prolonged service, but if you spent 35 minutes in prolonged service, you have to say what you did during that time."
 
Brink adds that the note can be short. It could be as concise as "counseled on changes in diet" or "went over with patient how to change colostomy bag." "It does have to be something where the auditor can see why the extra time was spent with the patient," she adds.

Gastroenterologists should not overuse the prolonged service codes; it's not feasible to use these codes with every E/M visit. "It's humanly impossible to see 20 patients a day for 60 minutes apiece," Brink notes. "You don't want to make a habit out of using these codes because it sends red flags to auditors."
 
"You're going to go broke if every follow-up visit lasts an hour," Weinstein says. "You may do that for a patient with hepatitis or Crohn's, but that's usually only one visit. The next 10 times you see them you won't be having that long of a discussion.
 
"Less than 5 percent of your office visits will qualify as prolonged services," Weinstein continues. "Most of them will be based on the standard history, exam and medical decision-making, but that other 5 percent is still one visit a day."
 
Kisloff notes that gastroenterologists who increase their use of prolonged care codes should decrease the number of upper-level E/M services they bill. "There's an honest tradeoff between upper-level E/M codes and prolonged services," he says. "We have fewer 99214s and 99215s. This really isn't a way to make more money, but a way to accurately show what you have done."