Gastroenterology Coding Alert

Question: We have a new gastroenterologist who seems very fond of adding prolonged service codes onto his E/M services. Is this allowable?

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Answer: Depending on the insurer’s rules and the documentation, it is likely allowable, but if the doctor is “very fond” of using these codes, he may be reporting them too often. However, the only way to find out is to read the documentation.

You should only use prolonged service codes to document unusual circumstances that go above and beyond the typical or average time of the documented visit code. To do that, it is important that you record the times for these time-based codes in the medical record. It is also important to remember that prolonged care face-to-face codes cannot be used if the initial time assessed to the base code has not been met. For example, you would have to have 55 minutes at a minimum to bill a 99214 (25 minutes) with a +99354 prolonged care code for the additional 30 minutes.

To familiarize you with these code, keep in mind that they are all designated as add-on services:

• +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).

You’ll use +99354/+99355 when the direct patient contact is provided by “a physician or other qualified health care professional,” according to CPT^® guidelines. But if you use +99415/+99416, you’ll need to document that the service was provided by clinical staff under the direct supervision of a physician or qualified health professional.

Always calculate time correctly and be aware of the different time thresholds. Prolonged time of less than 30 minutes for the physician codes or 45 minutes for the clinical staff codes is not separately reportable. This means you must be able to document an additional 30 to 74 minutes for +99354, an additional 45 to 74 minutes for +99415, and any additional time between 15 and 44 minutes with added units of +99355 and +99416.

Under these circumstances, when you report prolonged services, your time documentation needs to be precise. It should include details of important clinical matters — what happened in that face-to-face encounter — and it should also support coding.

You can also document services your provider performs when the patient is not present with two more codes:

• 99358 — Prolonged evaluation and management service before and/or after direct patient care; first hour
• +99359 — … each additional 30 minutes (List separately in addition to code for prolonged service).

Per CMS, you can report 99358/+99359, providing you can document prolonged communication consulting with other health care professionals related to ongoing management of the patient, prolonged review of extensive health records, and diagnostic tests regarding the patient. And, per CPT^® guidelines, the services must “relate to a service or patient where (face-to-face) patient care has occurred or will occur and relate to ongoing patient management.”

The time thresholds, however, remain the same as the face-to-face prolonged care codes. So, you can use 99358 to document the 30 to 74 minutes of non-face-to-face care and report additional units between 15 and 44 minutes with +99359. The same rules as +99354/+99355 and +99415/+99416 apply, only you don’t have to substantiate direct patient contact. Keep in mind that the service must be reported for a specific date – not provided across a series of dates.