General Surgery Coding Alert

And make sure to update 2 more.

General surgeons may not be the best about keeping on top of E/M documentation, but some changes coming down the pike next year should make you sit up and take notice.

If you miss these CPT^® 2016 code revisions and additions, you could be sacrificing significant E/M pay for your surgeons and other clinical staff.

Investigate 99415 and 99416 Surprise

CPT^® 2016 will add two add-on E/M codes to help you capture extensive work that your clinical staff performs after your surgeon sees the patient for an E/M service. The codes help you capture pay for prolonged services that you haven’t been able report the past.

Beginning January 1, you will have two new codes for these services, as follows:

• 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 services).

“Often, a physician’s time with the patient only paints a partial picture of what occurred during the visit,” says Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, director of PB Central Coding at Allegheny Health Network in Pittsburgh, Pa. “The staff [members] in a physician’s office are important to the care of the patient, and also are an expense to the physician,” so capturing this work could be a bonus to your practice.

Caution: Because “clinical staff” can’t bill Medicare, these codes may have a problem in practice. “We will have to wait and see what the explanation for this one is at the CPT^® meeting in November,” says Melanie Witt, CPC, COBGC, MA, an independent coding consultant in Guadalupita, N.M.

Update Codes 99354, 99355

New codes aren’t the only E/M change you’ll need to watch out for next year. CPT^® 2016 updates two existing prolonged services codes as follows (emphasis added to show the revisions):

• +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).

“Further clarifying when to use the code — ‘beyond the typical service time of the primary procedure’ — illustrates that you could add the code on to any service level; not just the highest. We’ll have to see how CMS develops policy around these clarifications,” says Hauptman.

Brush Up on Prolonged Service Rules

You should always report prolonged service codes in addition to a separate E/M code that has a typical or specified time in the code descriptor. The +99354 descriptor indicates it’s for the first hour of prolonged services, but as is so often the case with code descriptors, you can’t take the descriptor at face value.

Halfway rule: Do not report +99354 “for anything under 30 minutes (above the average time of the normal service),” says Jacqueline Mehalich, RN, CPC, CPC-H, manager of physician education at Allegheny Health Network in Pittsburgh, Pa.

In addition, you would not report the add-on code for an additional 30 minutes (+99355) “for anything that does not extend past the next 15 minutes,” Mehalich says.

Use the following table to get a snapshot of how you should use these codes to capture additional face-to-face time with the patient.

Takeaway pointers: The time involved with either code does not have to be consecutive, but it does have to be on the same day. You should use +99354 only once per date, even if the time the physician or other qualified health care professional spends is not continuous on that date. Use +99355 to report each additional 30 minutes beyond the first hour, depending on the place of service.