Medicare Compliance & Reimbursement

Myth: You can't bill prolonged service codes for the lengthy E/M services that your physician performs in nursing facilities.

Reality: CMS now confirms that you can collect for those prolonged services when your physician spends additional time with a nursing facility patient.

History: When you want to report prolonged services, you look to CPT to determine the typical time that a service should take. Without that benchmark, you can't know how much time a "prolonged" service should take.

But in 2006, CPT removed references to the typical time that practitioners should spend performing E/M services in nursing facilities, therefore no longer allowing these providers to report prolonged services or time-based counseling and coordination of care visits. CPT 2008 included new time guidelines that cover the codes in these categories, but CMS remained mum on whether Medicare would honor them, says Randall Karpf with East Billing.

CMS issued Transmittal 1489 on April 11 to clarify this issue, which states, "Medically necessary prolonged services for E/M visits [codes 99356 and 99357] in a SNF [skilled nursing facility] or NF [nursing facility] may be billed with the nursing facility services in the code ranges 99304-99310 and 99318." You can use the typical times noted in CPT as a reference.

For example: The physician sees a patient for a visit that lasts 20 minutes. He decides that the patient needs an x-ray, so the patient leaves and returns that afternoon, whereupon the doctor reviews the x-ray with the patient and discusses treatment options. This second visit lasts 30 minutes.

Solution: "Since the patient left to have the x-ray done and then returned to discuss the results with the physician, 99354 would be appropriate" to report with the E/M service, says Wayne Mathis of Tennessee Sports Medicine and Orthopaedics. "This service is reported in addition to other physician services, including E/M services at any level. To bill for prolonged services, the physician has to spend at least 30 minutes with the patient, but it does not have to be continuous," he says.

To read CMS Transmittal 1489, visit http://www.cms.hhs.gov/Transmittals/downloads/R1489CP.pdf.