General Surgery Coding Alert

Prolonged services codes can get you paid for extra time spent face-to-face If you find yourself struggling to gain reasonable compensation for long E/M visits, here's a valuable tip: Used sparingly and with care, prolonged services codes (99354-99357) can more than double your reimbursement when the surgeon must spend extended time with a patient. To apply these codes correctly, follow these five rules. Rule 1: Make Sure E/M Time Is Face-to-Face Before you can report prolonged services (99354-99357; see "Prolonged Services Codes"), you must determine that the surgeon spent additional time in direct, face-to-face contact with the patient.

CPT includes two codes for prolonged services without direct patient contact: 99358 and 99359. But Medicare has not assigned a relative value to these codes, and it instructs local carriers not to reimburse for these services. You may report these codes for the sake of accuracy, but do not expect payment from Medicare (or most private insurers).

You cannot count time spent discussing the patient's case with other physicians, time reviewing data or tests without the patient present, or other activities not involving direct patient contact toward prolonged services, says Suzan Hvishdash, CPC, physician education specialist for the department of surgery at UPMC Presbyterian-Shadyside in Pittsburgh. Rule 2: Report 99354-99357 With Approved Codes Prolonged services codes are time-based add-on codes. Therefore, you may append them only to other E/M codes that include a reference time (without this time component, there is no way to define a service as "prolonged"), Hvishdash says.

Specifically, according to section 15511.1 of the Medicare Carriers Manual (MCM), you should apply 99354 and 99355 only with:

99201-99205/99211-99215 -- Office or other outpatient visit, new or established patient
99241-99245 -- Office or other outpatient consultation.

Similarly, you must use 99356 and 99357 with:

99221-99223 -- Initial hospital care
99231-99233 -- Subsequent hospital care
99251-99255 -- Initial inpatient consultations
99261-99263 -- Follow-up inpatient consultations
99301-99303 -- Nursing facility assessments
99311-99313 -- Subsequent nursing facility care. Don't make the mistake of reporting prolonged services with hospital observation services, observation or inpatient care services (including admissions and discharges), critical care services or emergency department services. These services do not include a "reference time," so prolonged services do not apply. Rule 3: Document at Least 30 Additional Minutes If you wish to report prolonged services, the physician must document at least an additional 30 minutes beyond the reference time of the chosen E/M service level, says Sherry Wilkerson, RHIT, CCS, CCS-P, director of coding and compliance for Esse Health in St. Louis. For example, if you select an E/M service with a reference time of 15 minutes (such as 99231), the physician must document a minimum of 45 minutes of face-to-face time before you can report an [...]