General Surgery Coding Alert

Question: If a patient has had a stroke and cannot communicate or is otherwise unresponsive, and the physician has spent additional time for the care of the patient beyond the regular E/M codes for inpatient care (talking to the family, consulting with other physicians), may we report prolonged services (99356-99357)?

Minnesota Subscriber

Answer: If you provide and document the appropriate services, you may report +99356 (Prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service [e.g., maternal fetal monitoring for high-risk delivery or other physiological monitoring, prolonged care of an acutely ill inpatient]; first hour [list separately in addition to code for inpatient evaluation and management service]) and, if necessary, +99357 ( each additional 30 minutes [list separately in addition to code for prolonged physician service]).

You should report prolonged services in addition to other physician services, including E/M services at any level. Codes 99356-99357 are time-based, and 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"). Specifically, section 15511.1 of the Medicare Carriers Manual (MCM) dictates that 99356 and 99357 must accompany a claim of 99221-99223 (Initial hospital care), 99231-99233 (Subsequent hospital care), 99251-99255 (Initial inpatient consultations), 99261-99263 (Follow-up inpatient consultations), 99301-99303 (Comprehensive nursing facility assessments) or 99311-99313 (Subsequent nursing facility care).

You may not report prolonged services with hospital observation services, observation or inpatient care services (including admissions and discharges), critical care services and emergency department services (unless the physician is providing an outpatient consultation that goes beyond the typical time spent with a patient).

To report the first hour of prolonged services, the surgeon must exceed the reference time for the primary E/M service by a minimum of 30 minutes. For an additional half-hour of prolonged services, the total time required beyond the reference time of the primary E/M code must equal at least 75 minutes. The physician must account for at least 15 minutes of every additional half-hour billed. If warranted, you may report multiple units of 99357 (see chart in CPTfor additional explanation).

Note that the physician must provide (and document that he or she provided) the services face-to-face. Unlike the care plan oversight codes (99374-99380), prolonged services do not apply if the surgeon spends time arranging treatment in the patient's absence or discussing a patient's condition with other healthcare professionals. In the case of an unresponsive patient, you can count the additional time required to communicate with the patient (or family, as long as the patient is present), but not time spent away from the patient consulting with family, other physicians, etc.

Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb.