Internal Medicine Coding Alert

Catch: Medicare won't accept this CPT change.

Not capturing all the time your internist spends on a case is disappointing, but take heart -- your reimbursement efforts just got a boost from the loosening of the prolonged services descriptor in 2010.

Guideline revisions "liberalize prolonged non-face-toface services codes," reports Richard Tuck, MD, FAAP, at PrimeCare of Southeastern Ohio in Zanesville. "This CPT change is a really good one."

For 2010, you can count indirect prolonged service time that occurs around the date of the E/M service.  Under the old definition, the non-face-to-face service had to be the day of the E/M," Tuck explains.

Be careful: Prolonged service codes 99358 (Prolonged evaluation and management service before and/or after direct [face-to-face] patient care; first hour) and +99359 (... each additional 30 minutes [List separately in addition to code for prolonged physician service]) still have to relate to an E/M service that involves face-to-face patient contact. The prolonged service "must relate to a service or patient where direct [face-to-face] patient care has occurred or will occur and relate to ongoing patient management," according to the revised notes. CPT places no timeframe on the time that can elapse between the primary service and prolonged service.

Loosening of the prolonged non-face-to-face service codes could be a great help if your internist is seeing a complex patient, since you can count time spent looking at the patient's chart and making phone calls before she sees the patient.

Example: The physician evaluates a 70-year-old new patient with multiple problems. On subsequent days, the physician requires extensive time to confer with the patient's family, to review a complex, detailed medical history, and to formulate and coordinate a comprehensive treatment plan.

Under 2009 non-face-to-face guidelines, you could code only 99205 (Office or other outpatient visit for the evaluation and management of a new patient ... Physicians typically spend 60 minutes face-to-face with the patient and/or family) and 99358 for the first hour of non-face-to-face prolonged service the internist performed on the same day. You would not be able to report the work the internist did to complete a comprehensive treatment plan later in the week.

In 2010, you can tally each day's non-face-to-face prolonged service time before and after the encounter and report the applicable time-based code(s). The time is cumulative but does not have to be continuous, according to the revised guidelines. The codes' descriptors remain the same.

Medicare slant: Keep in mind that Medicare will reimburse only for face-to-face services. Medicare considers 99358 and +99359 bundled on the 2010 fee schedule, so reporting these codes to Medicare will not result in payment for prolonged services, points out Brenda Dombkowski, CPC, of the Yale University Department of Internal Medicine in New Haven, Conn.

Make sure you report the total prolonged services that occur on each day. "You can't add up prolonged services over a month," cautioned Peter A. Hollmann, MD, AMA CPT editorial panel vice chair, in his "Evaluation and Management" presentation at the AMA CPT and RBRVS 2010 Annual Symposium in Chicago on Nov. 12. Choose 99358 and possibly +99359 based on all the time the physician spends on indirect prolonged services on one day.

You need to spend at least 30 minutes of time to bill the first hour (99358) and at least 75 minutes to bill the first hour plus an additional 30 minutes (+99359) of prolonged time. The time needs to be carefully documented and be beyond the time specified in the E/M base code's CPT descriptor, such as 60 minutes for 99205, as well as the usual non-face-to-face component of the E/M base code, since the revised guidelines specify that codes 99358 and 99359 are used "when a physician provides prolonged service not involving direct (face-toface) care that is beyond the usual non-face-to-face component of physician service time."

Be careful that you don't double-dip on non-face-to face services. "You can't count time twice," warned Hollmann, who is also a medical director for Blue Cross Blue Shield of Rhode Island.

Example: Your office is billing phone calls (99441-99443, Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment ...) and non-face-to-face prolonged services (99358, and possibly +99359) that a physician provides to a patient. You would not include separately billed phone call time when assigning the prolonged services code(s).

Warning: "Do not report 99358-99359 for time spent in medical team conferences, on-line medical evaluations, care plan oversight services, anticoagulation management, or other non-face-to-face services that have more specific codes and no upper time limit in the CPT code set," according to the 2010 CPT manual. You can report 99358-99359, however, for time related to other non-face-to-face service codes that have a published maximum time (for instance, telephone services).

Last word: Not every payer may jump to liberalize prolonged services standards -- that's why it pays to verify with commercial payers whether these codes are recognized and/or payable, says Bruce Rappoport, MD, CPC, CHCC, a board-certified internist and medical director of Broward Health's Best Choice Plus and Total Claims Administration in Fort Lauderdale, Fla.