General Surgery Coding Alert

Prolonged services are a good way for general surgeons to get reimbursed for significant extra time spent caring for patients. Surgeons treating pediatric patients and those with cancers of the colon, for example, particularly stand to benefit financially by coding and billing for prolonged services when appropriate.

There are two hurdles to overcome, however, before these benefits can be realized:

1.) Many practices are unfamiliar with billing these
evaluation and management (E/M) services; and

2.) Many surgeons dont document their time adequately the critical compliance guideline when using and billing for these services and the key to successful reimbursement.

Billing the Two Types of Prolonged Services

There are two subcategories of prolonged services in CPT 2000: direct, or face-to-face contact and without direct contact. From a reimbursement standpoint, the face-to-face codes are far more useful because most carriers wont pay for nondirect prolonged services.

The face-to-face codes are further categorized as inpatient or outpatient. There are four codes:

99354 prolonged physician service in the office or
other outpatient setting requiring direct (face-to-face)
patient contact beyond the usual service (e.g., prolonged
care and treatment of an acute asthmatic patient in an
outpatient setting); first hour (list separately in addition to code for office or other outpatient evaluation and management service)

99355 each additional 30 minutes (list separately
in addition to code for prolonged physician service)

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)

99357 each additional 30 minutes (list separately
in addition to code for prolonged physician service)

Note: The term outpatient setting includes patients in the hospital for observation.

Coding Tips

Prolonged services codes cant be used on their own. The first thing to note about prolonged services codes is that they are add-on codes, which means they cannot be billed on their own but must accompany another E/M service, says Barbara Cobuzzi, MBA, CPC, CPC-H, an independent coding and reimbursement specialist in Lakewood, N.J. And because these codes are time-based, they can be added only to E/M services that have a time component or reference time built in, Cobuzzi says, such as hospital admissions, inpatient follow-up care, consults or office visits.

Note: When more than 50 percent of the physician/patient or physician/family encounter is spent counseling or coordinating care, time supersedes history, exam and decision-making and becomes the key for determining the level of E/M service.

Coders should not bill a prolonged service code as an add-on to an emergency department (ED) visit code (99281-99285) because these have no time component or reference time. As a result, there is no way to indicate what, was prolonged. You cant determine that a service is prolonged without a reference time, Cobuzzi says.

The surgeon can bill prolonged services, however, to get paid for time spent in the ED if he or she determines that the patient should be admitted. For example, a patient comes into the ED with trauma after a car crash, and the surgeon determines that the patient must be admitted because a lacerated spleen is suspected. The surgeon performs a full workup in the ED and then does a level-three admission (99223, initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: comprehensive history, comprehensive examination, and medical decision-making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patients and/or familys needs. Usually, the problem[s] requiring admission are of moderate severity. Physicians typically spend 70 minutes at the bedside and on the patients hospital floor or unit).

In this situation, Cobuzzi says, If the total time the surgeon has documented is equal to or exceeds 30 minutes beyond the reference time for the admit, the first hour of prolonged services (99356) may be billed. The surgeon did a level-three admit, which has a reference time of 70 minutes. If 101 minutes were spent with the patient within a 24-hour period (midnight to midnight) and can be documented between the ED chart and the admission chart (101-70=31), then both 99223 and 99356 could be billed.

Office visits also include reference times for those situations when counseling the patient or coordinating care comprises more than 50 percent of the visit. For example, during an office visit, an established patient is told about a colon cancer diagnosis. In this situation, the surgeon may spend 70 minutes with the patient counseling and/or coordinating care. Even with a level-five established patient code (99215, office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: comprehensive history, comprehensive examination, medical decision-making of high complexity ... Physicians typically spend 40 minutes face-to-face with the patient and/or family), only the first 40 minutes of the encounter are included. The remaining 30 minutes may be billed using prolonged services code 99354. Both 99215 and 99354 would be linked to a colon cancer diagnosis.

Note: One hour of prolonged services (99354 and 99356) is considered to be 30-74 minutes of documented time.

Document all the time spent with the patient. Prolonged services are one of three E/M code categories that are entirely time-based. (Critical care and care plan oversight are the other categories.) That means that the regular E/M categories history, exam and medical decision-making do not apply when billing for prolonged services. Instead, the amount of time spent face-to-face with the patient determines which code to bill.

General surgeons should document all the time they spend with the patient, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C. But remember, once youve passed the halfway point of any given segment of time, youll be given credit for the entire segment, she says.

For example, a surgeon performs incision and drainage of an abscess in the foot that required deep debridement of the abscess down to the bone. Two days later, the patient develops chest pain. Because the patients primary-care physician is unavailable, the surgeon is the only physician who saw the patient. Consequently, the surgeon coordinated care with the cardiologist by phone, transferred the patient to another hospital for a cardiac catheterization and checked on the patient regularly. A total of 80 minutes was spent seeing the patient and coordinating care.

In this scenario, the surgeon could bill 99233 (subsequent hospital care, level three), which includes 35 minutes as its base time. Modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period) should be appended to the 99233, which should be linked to ICD-9 code 786.51 (precordial chest pain). In addition, prolonged services code 99356 may be billed for the time spent with the patient that exceeded the 35 minutes allotted to the 99233. In this case, it exceeds 30 minutes.

Whenever prolonged services are billed, the time spent by the surgeon must be documented. A simple notation that the surgeon spent 45 additional minutes with the patient or 80 minutes total does not count. The documentation needs to include what was discussed and any other pertinent clinical information, such as the patients vitals, blood counts and why counseling was necessary or what the surgeon did to coordinate the patients care.

Medicare will pay about $100 for the extra 30-74 minutes documented, Cobuzzi says.

To charge for each additional half hour of prolonged services (99355 for outpatient, and 99357 for inpatient), at least 15 minutes of the additional 30 minutes claimed must be documented. With any time-based code, whether critical care or prolonged service, once 30 minutes of the first hour (30-74 minutes) is documented, youve met the documentation requirements for the first hour, Cobuzzi says. The same applies for the next 30 minutes, she notes; once 75 minutes of face-to-face contact is documented, the surgeon can charge for another half hour.

Note: Physicians should be consistent and document start and stop times, although they arent required.

Apply nondirect time to original E/M service. The 50-minute reference time for a level-two hospital admission includes time for counseling or coordination of care beyond 50 percent of the encounter. The time includes not only face-to-face time but also floor-time on the unit. The documented time to support billing with prolonged services codes 99354-99357 must be face-to-face time spent with the patient. For instance, if the physician spent a total of 80 minutes with the patient, at least 30 minutes must be direct or face-to-face contact. The physician, therefore, should document ordering labs or consults, conferring with other physicians or staff, and evaluating lab results, other chart notes and consults already performed, as these are all part of the floor time for any inpatient service and may be counted as part of the admission. Physicians can include all those seemingly extraneous tasks if they document what they did, Cobuzzi says.

If some of the floor time included in the admission code is spent talking to the family about the patients condition, that too may be included, Cobuzzi says. She notes, however, that encounters with family members should take place in the patients ward. Meetings in the chapel or the ED while doing other work do not apply.

Cobuzzi also recommends that physicians note in the patients chart that the admit is a continuation of the time already spent in the ED, although there is a separate ED chart. That way, she says, if someone reads the inpatient chart only, it can stand on its own.

Other Prolonged Services Codes and Modifiers

According to CPT, codes 99358-99359 (prolonged physician service without direct [face-to-face] patient contact) are to be used when a physician provides prolonged service not involving direct care that is beyond the usual service in either the inpatient or outpatient setting. Claims using these codes are rarely paid, says Mary Jean Sage, CMA-AC, president of The Sage Associates, a practice management firm based in San Ramon, Calif.

CPT 2000 also includes modifier -21 (prolonged services). Although this modifier is still in the manual, Sage says it is rarely used. No specific time (or reimbursement) is defined, and physicians are instructed to use it only with the highest-level E/M codes in any category. Most coding experts agree that this modifier has outlived its usefulness.

Note: Prolonged services were added to the E/M section of the CPT manual in 1995. Some payers use older versions of the manual and therefore do not recognize or pay for such claims. If your prolonged services claim is denied for no apparent reason, you should appeal. If positive results are not forthcoming, contact your states department of insurance.