Internal Medicine Coding Alert

Internists frequently spend a significant amount of time on patient care that does not involve actual contact with the patient. Conferences with family members, review of extensive medical records and phone callsboth with the patient and with other physicians and caregiversare all examples that are frequently seen in an internal medicine practice. However, getting reimbursed for these services can be difficult.

CPT allows for reporting these services with the codes 99358-99359 (prolonged physician service, without direct patient contact). But these codes are add-on codes, meaning the service must occur on the same day as another evaluation and management (E/M) service to the patient.

The definition of the prolonged services code is a service that is beyond what is able to be encompassed in the regular E/M services , explains Garnet Dunston, CPC, MPC, the immediate past national secretary of the American Academy of Professional Coders (AAPC) and an independent healthcare consultant with Dunston Enterprises in AZ.

Typically, the prolonged services codes are used when the physician spends time talking with the family following a regular patient visit, or spends an extensive amount of time reviewing the file, including past medical records.

Another example will be having the patient and family come in to discuss test results and make a decision about how to proceed, and then the patient is admitted, Dunston advises.

If the time spent in the office prior to the hospital admission exceeds 30 minutes, the time can be reported with a prolonged service code.

The hospital admission would be reported with an E/M code for initial hospital care (99221-99223), which would be considered the main E/M code to which the prolonged services were added on.

Medicare Doesnt Pay If Its Not Face-to-Face

Although there are relative value units (RVUs) assigned for prolonged services codes, 1.73 RVUs for 99358 and 0.87 for 99359, Medicare does not reimburse services that do not involve face-to-face patient care.

Many internal medicine practices dont use these codes because Medicare, and many payers, dont pay for them, advises Susan Callaway-Stradley, CPC, an independent coding consultant in Augusta, GA, who was recently named the AAPCs coder of the year for 1998.

However, some managed-care plans have been willing to reimburse for these services, and it may be worthwhile to address the issue in contract negotiations.

Note: Some groups use these codes to track their prolonged services, even though they are not reimbursed for them, she explains. If your contract with a managed care payer expires next year, it would pay to start tracking the codes now, so you will have the information available in time.

Four Coding Requirements

Here are the four CPT requirements for reporting prolonged services without direct patient contact:

1. Time reported must be 30 minutes or more beyond the normal amount of time for the E/M service. For example, notes Dunston, CPT indicates that a Level 3 office/outpatient E/M visit, new patient (99203) should require about 30 minutes spent with the patient and family. If the internist spends an additional hour after the patient leaves going over all of his or her medical records, then the additional time can be reported with 99358 (prolonged evaluation and management service before and/or after direct patient care, first hour.)

According to the CPT guidelines for these codes, any prolonged time less than 30 minutes is still included in the main E/M code and is not separately reportable.

2. Time does not have to be continuous. CPT also indicates that the time is not necessarily continuous but does have to occur on the same day. The internist might not have an entire hour after the patient leaves the office to go through the records all at once. But, if the time spent totals at least 30 minutes by the end of the day, the code could still be reported.

It is important to document the time, Callaway-Stradley adds. The physician should make a note of the time the prolonged services start and stop during the course of the day. That way, the coder will know to apply the appropriate code and, if the codes are questioned in an audit, the chart will include documentation of the time spent.

For example, the physician could spend 10 minutes at one sitting, 20 minutes at another, 15 minutes later that day, and then 15 minutes at the end of the day, Callaway-Stradley says.

As long as the time is documented, the code can be billed. It needs to be thorough documentation, she emphasizes. It isnt enough to record, Spoke on the phone with Dr. Smith about Mrs. Jones. The documentation should indicate what was discussed, as well as the length of time spent.

3. Use code 99359 for each additional 30 minutes. Reporting prolonged services is based on time, and CPT sets specific rules, which can be tricky. Code 99358 is for the first hour of prolonged services. But the code can be reported beginning with any time that is more than 30 minutes beyond the normal allotted time for the main E/M service. Beyond the first hour, code 99359 is for each additional 30 minutes; however, this code can be reported beginning with any time spent that is more than 15 minutes beyond the first hour.

A simpler way to think about it is to consider the normal amount of time allotted for the main E/M code that these services are prolonged from. Once the time spent on the main E/M service is up, you can consider reporting prolonged services.

An example would be if there is a new patient visit of 45 minutes and later that day the physician spends 30 minutes on the phone with the family and another 45 minutes reviewing the patients chart.

The new patient visit (30 minutes)99203;

The prolonged services beyond E/M services; first
hour (last 15 minutes of patient visit and 45 minutes reviewing the chart99358);

Prolonged services (beyond first hour; 30 minutes
with family99359).

4. Services do not have to be provided in the office. These codes allow for services provided on behalf of the patient at different sites. Telephone calls to the patient or patients family on the same day as a patient visit are a good example, Dunston notes.

Scheduling Family Conferences
on Separate Days

The prolonged services codes do not cover family conferences that occur on days that the patient is not also seen by the physician.

Some internal medicine offices have attempted to count such time as prolonged from another E/M service on a different day. This is definitely not correct, say both Callaway-Stradley and Dunston.

For the services to be considered added on to the main E/M service, they must occur on the same day, notes Dunston.

However, many internists schedule conferences with the patients family to discuss care options without the patient being present. This may happen in an internal medicine practice that sees adolescent patients with Attention Deficit Hyperactivity Disorder (ADHD), she says. The physician may want to see the parents without the patient there.

Or, in cases of elderly patients who are in nursing homes, the internist who is coordinating their care may schedule a conference with the family at his office. Again, Medicare will not pay for any care that does not involve direct contact with the patient.

But, for payers who do recognize these services, Callaway-Stradley advises considering an office/outpatient E/M code for these conferences. Remember the office/outpatient E/M codes are used to report counseling and coordination of care as well. When more than 50 percent of a visit is comprised of counseling, then you code based on time, using the guidelines for each code, she says. And the definition for each code states that the services are provided to the patient and/or family.

This indicates that 99201-99205 (new patient) or 99211-99215 (established patient) can be used to report conferences for family members that do not take place on the same day as an E/M service provided directly to the patient.

You would assign a separate E/M code rather than the prolonged services E/M code for these visits, she states.

Again, Medicare will not pay for these types of visits, but other payers might, so check with your top carriers.

In addition, Callaway-Stradley recommends advising the family before the conference occurs that they will be billed for the time as if it were an office visit.