Medicare Compliance & Reimbursement

Remember those E/M codes for prolonged services that CMS offered up back in the fall and applicable in 2017? New guidance suggests that those unbundled, CPT^® options for non-face-to-face, prolonged care will be limited to two hours total.

In its final rule for the 2017 Medicare Physician Fee Schedule (MPFS) in November 2016 (see more details on the 2017 MPFS in Medicare Compliance and Reimbursement, Vol. 42, No. 22), CMS pledged separate payments for some E/M services that fell under CPT^® codes 99358 (Prolonged evaluation and management service before and/or after direct patient care; first hour) and 99359 (Prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes [List separately in addition to code for prolonged service]) with the start date of Jan. 1.

However CMS issued a medically unlikely edit (MUE) for the codes to go into effect on April 1, 2017. Here’s the gist of the MUE: You will only be able to claim two units of the add-on code 99359 per day, suggests MLN Matters release MM 5972. Since 99359 is added onto 99358 after the first hour, that only allows for a maximum of two hours of reportable time on your claim.

“Documentation is required to be in the medical record about the duration and content of the medically necessary evaluation and management service and prolonged services that you bill,” MLN Matters reminds. These new CMS time thresholds aim to hold providers accountable to the medical necessity of the prolonged care, suggests the guidance.

To read MLN Matters release MM 5972, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/mm5972.pdf.