Internal Medicine Coding Alert

AMA ushers in more specific way to report prolonged services.

Have you tried adding modifier 21 onto a 99214 or 99223 that took longer than usual, only to receive a denial because the code was not the highest level of E/M service for the category?

CPT 2009 eliminates this pitfall by taking you directly into prolonged services codes.

Before you start adding +99354-+99357 onto an E/M service, check out these changes coming in January. (At press time, Medicare had not commented on the AMA's changes to prolonged service coding in CPT 2009. CMS will likely publish a clarification in response to these changes before Jan. 1.)

The prolonged service code revisions that take effect next year coincide with modifier 21's elimination. According to CPT 2009's Appendix A, "Modifiers," "Modifier 21 has been deleted. To report prolonged physician services, see 99354-99357."

This should make things easier for coders when considering prolonged service codes, experts say. Often, "providers and billers would forget that modifier 21 (Prolonged evaluation and management services) was allowed only for the highest level E/M code in a category, recalls Lynn A. Brown, CPC, director of physician coding and reimbursement at CHS in Birmingham, Ala. Per CPT 2008, Appendix A, you would use the modifier only with "the highest level of E/M service within a given category" and only on an E/M code.

According to Joan Gilhooly, CPC, CHCC, president of Medical Business Resources in Chicago, modifier 21 has been living on borrowed time for years. 

"Prolonged service codes were added to CPT in 1994, when modifier 21 already existed. This created a bit of redundancy, because if you can report prolonged service by using the [99354-99357] codes, what is the purpose of modifier 21?" she asks.

Impact: Some coders won't be affected much by modifier 21's deletion. "Not many practices that I work with were using modifier 21 in the first place," relays Heather Corcoran with CGH Billing in Louisville, Ky.

Brown concurs, saying "eliminating this modifier will simplify the [prolonged services] decision."

Using a +99354-+99357 code, rather than modifier 21, also provides more description.

"The prolonged E/M service codes clarify whether it was face-to-face time with the patient, and specify exactly the time parameters involved," explains Jennifer Swindle, RHIT, CCS-P, CPC-EM-FP, CCP, director of coding compliance/charge entry for QLIMG, and director of the coding and compliance division of PivotHealth LLC in Garden City, N.Y.

Providers should code the level of care based on medical necessity and time. Report E/M services 30 minutes beyond the usual service for direct patient care using prolonged services codes +99354-+99357.

2009 example: A visit, in which the E/M medical necessity level meets the criteria for 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity ... Usually, the presenting problems are of moderate to high severity ... Physicians typically spend 25 minutes face-to-face with the patient and/or family), takes 70 minutes. This visit would be eligible for an additional prolonged service code of +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient evaluation and management service]) with 99214, Brown says.

2008 example: In the office setting, you could have used modifier 21 on only 99215 (... a comprehensive history; a comprehensive examination; medical decision making of high complexity ... Usually, the presenting problems are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family), but the visit's medical necessity might not have warranted reporting this level of care.

When you report office-setting prolonged service codes (+99354 and +99355, ... each additional 30 minutes [List separately in addition to code for prolonged physician service]), "the patient and provider must meet face-to-face during the encounter," Gilhooly states. However, the inpatient prolonged service codes substitute "face time" with "unit/floor time."

The CPT 2009 descriptor for +99356 reads: (Prolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual service; first hour [List separately in addition to code for inpatient Evaluation and Management service]). The new language is an important clarification coders should digest before Jan. 1.

Reason: In CPT 2008, +99356 required "direct [face-to-face] patient contact." Now, the coder only needs to count "floor/unit time" when considering prolonged service codes. (For more information on inpatient prolonged service reporting, see the next story, "Expert Cheers Revisions to +99356, +99357.")

If you were one of the lucky few getting paid for 99215-21, CPT 2009 will disappoint you. "Prolonged service of less than 30 minutes total duration on a given date is not separately reported because the work involved is included in the total work of the evaluation and management codes," according to new CPT notes for +99354 and +99356. Therefore, the AMA deleted modifier 21.

Loss of payment on soon-to-be-included prolonged services, however, will probably not be widespread. Payers in some areas do not recognize modifier 21, according to Brown.

Expect an easier time getting paid for prolonged services that a physician provides directly to a patient. Most payers recognize prolonged services codes for direct patient care, but not for indirect care, Brown relays.