Medicare Compliance & Reimbursement

3 steps help you keep your pay despite CPT's deletions.

If you're used to adding modifier 21 to E/M codes to capture additional reimbursement when your physician spends longer than normal with a patient, now's the time to revamp your coding.

CPT 2009 deletes modifier 21 (Prolonged evaluation and management services) effective Jan. 1, directing you to look instead at the prolonged service codes (+99354-+99357). Here's the scoop on what you'll need to know to avoid denials come Jan. 1.

In the past, you've been able to append modifier 21 to the highest level E/M codes in a grouping -- for example, 99205, 99215, or 99245. Modifier 21 was an informational code and did not require carriers to give you extra reimbursement. However, this modifier was often confusing for coders who didn't know whether they should add modifier 21 to their E/M services.

Update: Now, you'll simply turn to a +99354-+99357 (Prolonged physician service ... requiring direct [face-to-face] patient contact ... ) code, rather than modifier 21. CPT will change the introductory notes to the +99354-+99357 series for 2009, including the new statement, "The use of the time-based add-on codes requires that the primary E/M service have a typical or specified time published in the CPT codebook."

This change allows coders to provide more description, experts say. "The prolonged E/M service codes clarify whether it was face-to-face time with the patient and specify exactly the time parameters involved," explains Jennifer Swindle, RHIT, CCS-P, CPC-EM-FP, CCP, director of coding compliance/charge entry for QLIMG, and director of the coding and compliance division of PivotHealth, LLC in Garden City, N.Y.

Know +99354 through +99357

You should code the level of care based on medical necessity and time. Report E/M services 30 minutes beyond the usual service for direct and indirect patient care using prolonged services codes +99354-+99357.

Example: A visit in which the E/M medical necessity level meets the criteria for 99214 (Office or other outpatient visit ... Physicians typically spend 25 minutes face-to-face with the patient and/or family), takes 60 minutes. This visit would be eligible for an additional prolonged service code of +99354 (Prolonged physician service in the office or other outpatient setting....) with 99214.

Remember that codes +99354-99357 are time-based and are add-on codes. You do not need to append a modifier to these codes and you should not decrease their reimbursement when billed with other primary E/M codes.

2008 method: In the office setting, you could have only used modifier 21 appended to 99215 ( ... a comprehensive history; a comprehensive examination; medical decision making of high complexity ... Usually, the presenting problem[s] are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family), but the visit's history, physical examination, and the medical necessity might not have warranted reporting this level of care.

If you were one of the lucky few getting paid for 99215-21, CPT 2009 will probably disappoint you. "Prolonged service of less than 30 minutes total duration on a given date is not separately reported because the work involved is included in the total work of the evaluation and management codes," according to new CPT notes for +99354 and +99356.