General Surgery Coding Alert

Earn an Additional $120 for Extended E/M Services

Published on Tue Apr 27, 2004

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 initial prolonged service code.

Helpful Tip #1: To find the reference time for a particular E/M code, look to the last sentence of the CPT descriptor. For example, the final sentence in the descriptor of 99202 (Office or other outpatient visit ...) specifies, "Physicians typically spend 20 minutes face-to-face with the patient and/or family." In this case, 20 minutes is the reference time.

If you wish to report more than an hour of prolonged services, the physician must document a minimum of 75 minutes beyond the chosen E/M service's reference time. Returning to the above example, if the surgeon spends at least 90 minutes with the patient and reports 99231, you may also code for prolonged services using 99356 (for the first hour of prolonged services beyond the 15-minute reference time of 99213) and 99357 (for the additional 15 minutes of prolonged services beyond the first hour).

Helpful Tip #2: You can find a complete list of "threshold times" for reporting prolonged services with individual E/M services in the MCM, section 15511.1, subsections "E" and "F."

Coding Example: The surgeon meets with an established patient with recurrent hernias. The surgeon provides an E/M service that -- measured by the key components of history, examination and medical decision-making -- qualifies as a level-three outpatient visit (99213). But because the surgeon spends time discussing a proposed surgery with the patient, the visit requires 57 minutes -- 42 minutes beyond the 15 minutes allotted (per CPT guidelines) for a level-three established patient office visit. In this case, because the surgeon provided longer-than-typical service (requiring 42 minutes longer than usual), you may report 99213 and 99354.

If warranted, you may report multiple units of 99355 or 99357. For instance, returning to the above example, you would report a two-hour visit as 99213, 99354, 99355 x 2 (120 minutes - 15 minutes reference time = 105 minutes, or one hour plus 30 minutes plus 15 minutes).

Rule 4: Document Time

To gain reimbursement for prolonged services, you must document all time the physician spends face-to-face with the patient.

"Time documentation is the essential key to billing for prolonged service codes. Without an actual minute value stated in the physician notes, prolonged service codes are not valid no matter how much time the physician actually spent," Wilkerson says.

But the time you count toward prolonged services need not be continuous, although it should occur on the same date of service. The surgeon may consult with a patient in the hospital, spend 30 minutes discussing his condition, leave to perform regular rounds, and return to the original patient for another 40 minutes of counseling. The time spent with the patient both before and after the surgeon made rounds can contribute toward prolonged services.

Give a reason: You must explain why the physician provided prolonged services, according to MCM instructions (section 15511.1). Simply noting that the surgeon spent an extra 42 minutes with the patient is not adequate. You must prove, in the medical record, the medical necessity for the extra time spent, Hvishdash says.

Rule 5: Don't Overuse Prolonged Services

You must be careful not to use prolonged service codes too frequently. On average, you should report 99354 only once every 1,000 claims, while you should report 99356 only once every 100,000 claims, according to CMS estimated usage rates.

"We've only had one surgeon bill for these services in the past year," Hvishdash says. "And Medicare did honor those claims."

Therefore, you should reserve prolonged services codes for truly time-consuming services, such as when a patient is noncompliant or requires special attention due to a mental or physical handicap, or if the surgeon must explain complex diagnoses, treatment options or substantial lifestyle changes to the patient.