Sparse Use of Prolonged Service Codes Is Profitable
Published on Wed Nov 01, 2000
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 [...]
