Internal Medicine Coding Alert

Question: The internist saw a Medicare patient with a complicated history in the office for 100 minutes. Based on the documentation, I can report 99215, but this code represents only a 40-minute visit. Should I attach modifier 21 or prolonged service code 99354 for the additional 60 minutes?


Arizona Subscriber


Answer: You should use modifier -21 (Prolonged evaluation and management services) only for the "highest level of evaluation and management service," according to CPT guidelines. But Medicare payers typically use the modifier for informational purposes, and don't pay your internist for the additional time spent with the patient.

Therefore, your best bet is to report prolonged service add-on code +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact ...; first hour [list separately in addition to code for office or other outpatient evaluation and management service]) along with 99215 (Office or other outpatient visit for the evaluation and management of an established patient...).

Be sure your documentation supports using 99354. You should report prolonged care codes only for your internist's face-to-face patient service "that is beyond the usual service in either the inpatient or outpatient setting," according to CPT.

You shouldn't use prolonged care codes when nonphysician staff treat a patient. The documentation should include the total amount of time spent with the patient. All time-based codes such as 99354 require the physician to have documented the time spent face-to- face with the patient.