Gastroenterology Coding Alert

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 used to report the first 60 minutes of prolonged services. Code 99355 is used to report each additional 30 minutes of prolonged service in an office or outpatient setting, and 99357 is used to report each additional 30 minutes of prolonged service in an inpatient setting.

3. Prolonged Service Is Direct, Face-to-face Contact With the Patient. Although CPT includes a section on prolonged services without direct patient contact (codes 99358 and 99359), Health Care Financing Administration (HCFA) has not assigned a relative unit value to those codes. Neither Cobuzzi nor Laureen Jandroep, OTR, CPC, CCS-P, president of A+ Medical Management & Education, a medical billing and outsourcing services company in Egg Harbor, N.J., are aware of any payers that are reimbursing claims with these codes.

On the other hand, inpatient E/M service codes are based on unit/floor time, not face-to-face time. Therefore, prolonged services codes for that setting can include time the gastroenterologist spends doing charts or arranging for testsas long as those tasks are done while in the hospital unit.

4. Not All Payers Recognize Prolonged Service Codes. For example, Blue Cross Blue Shield of New Jersey is one commercial insurer that Cobuzzi knows does not reimburse claims submitted with prolonged service codes.

Proper Documentation Needed to Back Up Claim

Prolonged service codes also require detailed documentation. The gastroenterologist must explain in the chart what was covered during the visit and why it was necessary to take an extended amount of time, says Cobuzzi. If extra time was required because the patient was hard of hearing and had to have everything repeated, then the gastroenterologist should specifically note that in the patients chart.

A critical part of the documentation in these cases is noting the time spent on the visit. Gastroenterologists need to write down the start and stop time of the visit, the total time spent and the time spent on prolonged services, according to Jandroep. She also encourages her clients to give a complete breakdown of the visit by noting how much time was spent on the patients history, examination, medical decision-making, and counseling and coordination of care.

Tracking Time Is Critical but Difficult

Although noting time is crucial when documenting prolonged services, gastroenterologists often have difficulty tracking how long they spend on their E/M visits. Gastroenterologists dont think about the time component of their E/M visits, says Janel Flachsbart, MHA, practice manager at Consultants in Gastroenterology, a practice in Lincoln, Neb., with three gastroenterologists. They tend to concentrate on the other three components of the evaluation.

Cobuzzi thinks thats because gastroenterologists have been trained not to think about time. Theyve been told since 1992 that time doesnt matter, she explains. Its not part of their routine, and its a hard habit to develop.

For gastroenterologists who have difficulty tracking time, these suggestions may help:

1. Put a Clock on the Wall in the Examination Room Behind the Patient. Gastroenterologists dont like to look at their watches during a visit because they feel it might make the patient uncomfortable, according to Cobuzzi. When a clock is stationed on the wall behind the patient, the gastroenterologist will see the time when he or she says hello and good-bye to the patient. A clock posted next to the wall where the gastroenterologist picks up and deposits the patients chart also will work.

2. Use a Template to Help Document E/M Visits. Many gastroenterologists have templates containing the major components of the E/M visit to standardize their documentation, claims Jandroep. In addition to leaving room for the chief complaint, vital signs, history, exam and medical decision-making, there should be a box to note the time in and time out, she says.

3. Use a Dictation Service to Make Charting Easier. Jandroep has set up some of her clients with a service that allows them to dictate their patients medical charts by phone when the visit is over. The service can be designed to specifically prompt gastroenterologists for their start and stop times. The dictation service has the added advantage of allowing the gastroenterologists to be more thorough in their reporting because they dont have to write as much, according to Jandroep. It also can eliminate some of the guesswork involved in trying to decipher illegible handwriting.

Beware of Higher E/M Visits vs. Prolonged Service

Because gastroenterologists are uncomfortable with the documentation requirements for prolonged services, many try to take what they think is the easy way out by simply increasing the level of E/M service. If an established patient comes in for an office visit that might normally take 10 minutes but ends up taking 40 minutes because the patient does not speak English clearly, a conservative gastroenterologist might increase the E/M visit from a level two (99212) to a level three (99213).

By settling for a level three office visit in this case, the gastroenterologist is getting shortchanged. A level three office visit pays about $44 in New Jersey, says Cobuzzi, while the prolonged service code 99354 pays close to $99. In addition to the prolonged service fee, the gastroenterologist will get paid approximately $32 for the level two office visit.

In deciding whether to use a higher level E/M code or a prolonged service code, you have to look at whats causing the increase in time, says Jandroep. If it took longer because of the patients history, the exam, the medical decision-making, or counseling and coordination of care, then you would want to increase the level of E/M visit.

If the visit was extended because of circumstances other than the usual E/M components, however, a prolonged service code should be used.

Although Cobuzzi feels that many gastroenterologists are missing out on significant reimbursement by not using prolonged service codes, she also warns against the overuse of them. Not more than 5 to 10 percent of a gastroenterologists E/M visits should have prolonged services added to them, she cautions. If you have too many, that will be a red flag to an auditor. And dont use them at all if you arent going to take the time to do the proper documentation.