Gastroenterology Coding Alert

But make sure you're abreast of all the rules before using codes

Reporting an evaluation and management that takes longer than usual can be tricky business. For example, if your practice doesn't use prolonged service codes when a patient's mental incapacities increase the service time, you could be missing out on legitimate payment.

On the other hand, if you report prolonged service codes when some other course of action would have been more appropriate, your office could land in hot water. Here is a closer look at the prolonged service codes, when to use them, and when you're better off not using them. Prolonged Services for More Than a Few Minutes
 
Before even considering prolonged service codes, you need to know a couple of vital rules.
 
First, these codes are designed for physicians "who spend an inordinate amount of time, specifically 30 minutes, greater than the AMA's stipulated time limit for a given level of E/M service," says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa.

Translation: If the gastro takes 10-15 minutes longer than normal to complete an E/M service, you should not report a prolonged service code.

The second rule you must remember is that prolonged service codes are add-on codes, so they must be tagged to E/M services, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J. Do not report prolonged service codes alone, and never attach them to procedure codes.

Prolonged Service Codes Depend on Setting Which prolonged service code set you use will directly relate to the setting; you must know where the service took place, or the claim could go out with the wrong codes.

Example: An established male patient with symptoms of stress-induced incontinence reports to the office, and the gastro performs a level-two E/M service. The visit takes 45 minutes, and level-two established patient E/M services typically take about 15 minutes, so a prolonged service code should accompany the E/M code on this claim.

The gastroenterologist provided prolonged services in this situation. On the claim, you should:
   report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history, a problem-focused examination, and straightforward medical decision-making) for the office visit
   report +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]) for the prolonged service time 
   attach ICD-9 code 788.32 (Stress incontinence, male) to 99212 and 99354 to account for the patient's incontinence.
 
When reporting prolonged services, use [...]