Internal Medicine Coding Alert

As primary care providers, internists must often spend more time on patient care than might normally be expected in a regular office visit.

Supervising breathing treatments for asthma patients, explaining test results, and meeting with family members to explain a patients care, are just some examples of services that may require an extended amount of an internists time.

To recognize this, CPT has two methods of documenting these prolonged E/M services : modifier -21 (prolonged evaluation and management service) and the procedure codes 99354-99357 (prolonged physician service with direct patient contact), and 99358-99359 (prolonged physician service without direct patient contact).

However, because Medicare (and most other payers) dont have a set allowance for the -21 modifier, most practices will find it more profitable to use the prolonged care codes, says Cynthia C. Thompson, CPC, senior coding consultant with Gates, Moore, and Company in Atlanta, GA.

If you look at published allowables, it often doesnt tell you what they will do for modifiers. Sometimes it does; for example, modifier -80, the assistant at surgery, they will pay 16% of the total, she notes. But they dont list anything for the -21 modifier. It can be coded. But, its not clear that they are going to pay anything more for it.

Charlene Bakerink, community coding supervisor for Lutheran Health Systems in Fallon, NV, says she has never seen the -21 modifier attached to an E/M code in her practice. We have the prolonged services codes, so we just use those.

Because these codes indicate a specific amount of time the provider spent with the patient, they are more practical and provide documentation that justifies increased payment, she explains.

The prolonged services codes 99354-99357 (prolonged physician service with direct patient contact) have listed relative value units ranging from 2.6 to 2.64. Codes 99358 and 99359 (prolonged physician service without direct patient contact) also have listed RVUs, but they are lower1.73 for 99358 and 0.87 for 99359.

The last two codes are not as useful because Medicare doesnt allow any payments on services that are not face-to-face, says Thompson. However, they can still be used.

Coding 99354-99357 (With Patient Contact)

The most important things to remember when using these prolonged services codes are that they must be used in addition to the office-visit E/M code, and that the provider must exactly document the amount of extended time spent with the patient, says Thompson.

The first 30 minutes are included in the original office visit and cannot be billed separately, Thompson explains. After that, the code you choose depends on how much time is spent with the patient.

Here are some keys to coding prolonged physician services with direct, face-to-face contact.

1. Only direct patient time can be documented. Only that time that the physician spends in the actual presence of the patient will count toward the prolonged time. For example, says Thompson, the internist begins a nebulizer breathing treatment with an asthma patient following an office visit. The physician starts the treatment, spends 20 minutes with the patient, then leaves the nurse to administer the medication while he or she attends to another patient. Even though the physician is supervising the treatment, only the 20 minutes spent in the actual presence of the patient is reportable, she explains. In this case, 20 minutes is not enough time to report. At this point, the service would still be included in the regular office visit.

However, most asthma treatments require a substantial amount of a providers time. The patient may be there two or three hours, she notes.

2. Face-to-face time does have to be on the same day, but does not have to be continuous. If in the above situation, the physician were to return to the patient receiving the nebulizer treatment to check on his or her progress, discharge the patient, or order an additional treatment, and spent an additional 15 minutes, this would be billable using 99354.

This code and 99356 for the inpatient setting are for anything above 30 minutes up to 74 minutes, Thompson says. Each 30 minutes after the first 74 would be billed with 99355 for the outpatient setting and 99357 for the inpatient.

3. Notes in patient record help document prolonged services. The physician can most accurately track the amount of time spent on this type of care if he or she jots a note in the patients chart upon entering and leaving the room. This can also be used to support the codes on the claim form, if a payer questions the use of these codes.

Coding 99358 and 99359 (Without Patient Contact)

The codes for prolonged physician services without direct, face-to-face patient contact are usually used when the internist must spend an extended amount of time on a patients care when the patient is not present (i.e., reviewing medical records and/or tests, or communicating with other providers or a patients family members).

Most of the time you would see this happen when, for example, you have a patient coming in for a nursing home assessment for the first time, Thompson states. You would do the complete exam, etc. But, then youve got the family members there and you might spend 30 minutes or more with them. This is the way that can be billed.

The code 99358 (prolonged E/M service before and/or after direct, face-to-face patient care, first hour) can be billed starting after the first 30 minutes. Code 99359 is used for each 30 minutes after that. Both of these codes can be used regardless of the place of service, either inpatient or outpatient.

However, as noted above, Medicare does not reimburse these codes and most other third-party payers take the same stance. The codes are valid and can be billed to the patient, if the payer contract allows balance billing. However, not many providers do this.

Use Codes for Documentation

Even if the practice doesnt want to charge for the prolonged services, they should still use the codes (with a zero charge) to document the time they spent on the patients care, Thompson believes.

Many payers, particularly managed care companies, are beginning to track physicians productivitymonitoring the number of patients seen per day, etc.

If the internist is spending an extended amount of time on patient care that is not being documented in some way, it may look to the MCO that the physician is just not as productive.

We know of a number of HMOs that track physicians productivity, even down to tracking their phone calls, Thompson adds.