Use of Prolonged Service Codes Can Significantly Increase E/M Reimbursement
Published on Tue Feb 01, 2000
Gastroenterologists who are not using prolonged service codes when they spend an extended amount of time with a patient could be missing out on significant reimbursement.
The prolonged service codes (99354-99357) are used when a gastroenterologist has face-to-face contact with a patient that is beyond the usual service in either the inpatient or outpatient setting, according to CPT. These codes are used in conjunction with evaluation and management (E/M) service codes to report excess time spent with the patient, says Barbara J. Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions Inc., a physician billing and consulting service in Lakewood, N.J., which has presented training seminars to gastroenterologists.
Cobuzzi outlines several reasons why an E/M visit might turn into a prolonged service, which include:
- the patient is noncompliant with chosen treatment options;
- the patient has difficulty understanding the gastroenterologist because of mental handicaps, physical handicaps or language barriers;
- the gastroenterologist has to explain complex treatment options, such as major surgery, to the patient; and
- the gastroenterologist has to explain lifestyle changes that the patient must make, as in cases of hepatitis or cirrhosis.
Reimbursement Is Higher
For example, a gastroenterologist takes 90 minutes to inform a patient that the lesion he or she had biopsied a few days ago is malignant and to explain both surgical and non-surgical treatment options. The CPT guidelines suggest that the highest level of office visit, 99215, will take 40 minutes. The remaining 50 minutes can be coded as a prolonged service.
By adding a prolonged service code, reimbursement for the visit in this example will increase significantly. The gastroenterologist could bill both 99215 (office or other outpatient visit), which has a relative value unit (RVU) of 2.97, and 99354 (prolonged physician service in the office or other outpatient setting), which has 2.88 RVUs.
Four Important Points to Remember
To use these codes appropriately and effectively, gastroenterologists should be aware of four stipulations that come with prolonged service:
1. Prolonged Service Codes Are Add-on Codes. These codes always are used in conjunction with another code. They can be used for inpatient, outpatient, and office visits or consultations but cannot be used with emergency room (ER) visits. If an ER patient is admitted to the hospital, however, the time spent with the patient in the ER can be added to the admission code as a prolonged service, according to Cobuzzi.
2. The Prolonged Service Must Last at Least 30 Minutes, but the time spent does not have to be continuous. This is in addition to typical timeaccording to CPT guidelinesspent on the E/M service. Codes 99354 and 99356 (prolonged physician service in the inpatient setting) are [...]
