Neurology & Pain Management Coding Alert

Strict reimbursement guidelines sometimes cause physicians to feel they are giving away their time when an office or inpatient procedure runs longer than expected. When extra time is spent with a patient that involves direct (face-to-face) patient contact beyond the usual service, you often can obtain fair reimbursement for extended procedures by using prolonged service codes (99354-99357).

For example, you might have to take extra time with a cerebral palsy patient because the patient isnt able to cooperate during an exam. That might qualify as a prolonged service, says Shelly Kramer, MPA, RRA, audit compliance specialist with Boston Medical Center.

Choosing Correct E/M Code

Be sure to select the appropriate evaluation and management (E/M) codes for the service. This is essential because prolonged service codes are always used as an adjunct to other service codes (i.e., the prolonged service codes cannot be claimed by themselves).

Note: The prolonged service codes are not just for counseling services but can be used for any extended service with an office E/M or outpatient code.

Keep in mind that codes 99354-99357 are used with the E/M service code for additional time spent face-to-face with the patient. However, the time spent must exceed the time allowed in that E/M code by at least 30 minutes before the prolonged service codes may be used. According to the CPT manual, code 99354 or 99356 is used to report the first extended hour of prolonged service on a given date. Either code may be used to report a total duration of prolonged service of 30 to 60 minutes on a given date, even if the time spent by the physician is not continuous on that date. You must document your time to warrant the use of these codes.

Code 99355 or 99357 is used to report each additional 30 minutes beyond the first hour (99355 is used in conjunction with 99354, and 99357 is used in conjunction with 99356). Either code may also be used to report the final 15 to 30 minutes of prolonged service on a given date. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.

Eight Rules for Using Prolonged Service Codes

1. The physician actually must be present with the patient. Codes 99354-99357 are very clear: This is face-to-face time between the physician and the patient. The doctor cant just be writing in the patients records in his office, says Kramer. The doctor is seeing the patient and administering care.

Kramer warns that physicians should guard against claiming unearned face time. An auditor will look at a physicians schedule for the whole day. Theyll look at how many patients he had, how much time he claimed, and theyll see if it was possible for him to have devoted an extra 30 minutes or an hour to several patients in a one-to-one situation. Be very careful how you count this time.

2. Interruptions are OK. Realistically, few physicians can spend an uninterrupted hour with a patient. More likely, theyll be in and out of the exam room as they attend to other patients, phone calls and other practice matters. You can still bill using the prolonged service codes. You count the total time the doctor spends with the patient, even if its not continuous.

3. Remember the 30-minute rule. Anything less than 30 minutes doesnt qualify as a prolonged service. In fact, the codes are used to indicate 30-minute increments of care. Code 99354 indicates the physicians service took longer than 30 minutes in either an office or outpatient setting. Code 99356 is used if the service took place in an inpatient setting. And if the service extends an additional 30 minutes? Use code 99355. (See chart on this page for time limits.)

4. Chatting is not a physician service. As much as we wish there were more time for the fabled bedside manner, it doesnt qualify as a prolonged service. There has to be a clear medical necessity, says Kramer. It cant just be a matter of the doctor being generous with his time.

Generally, medical necessity will mean that the patients condition made it necessary for the doctor to take more time than normal. For instance, its not uncommon for patients to present to neurologists with unspecified sources of pain. Symptom-based diagnoses seen in neurologists offices include such things as pain in limb (729.5).

In such a case, the physician might perform nerve conduction studies (95900-95904). But the tests might take longer than expected either because of sensitivity in the patients limbs or because the doctor has to test multiple sites.

5. Get it in writing. Obviously, the prolonged service code is ripe for abuse. If your practice gets selected for an audit, prolonged service claims will be scrutinized. The physician should carefully document exactly why the procedure took longer than what usually is allowed by the evaluation and management codes.

6. Prolonged is not the same as slow. If a procedure just took longer than usual but there werent any complications, you probably cant bill for a prolonged service, says Gregory Schnitzer, RN, CPC, CPC-H, CPC-P, an audit specialist with the University of Pennsylvania in Philadelphia. Schnitzer audits hospitals and clinics at the universitys health system. Prolonged service codeswhich he says too often fall into gray areasfrequently catch his attention as he tries to find mistakes before they cause a payer to reject reimbursement.

The CPT manual is clear on this point: A prolonged service is beyond the usual service.

7. Match prolonged service codes with correct E/M code. These are add-on codes, always billed with an E/M code.

Use 99354 and 99355 with office or other outpatient services (99201-99215), consultation (99241-99245) or nursing facility services (99301-99350).

Use 99356 and 99357 with hospital inpatient services (99221-99233), initial inpatient consultations (99251-99255) or follow-up inpatient consultations (99261-99263).

8. Counseling has different rules. Theres a bit of confusion about whether you bill a prolonged service code or counseling/coordination of care codes, says Schnitzer.
The key here is the 50 percent rule, says Schnitzer. If more than half of the doctors time with the patient was spent in counseling or coordination of care, then you must bill according to the CPT counseling guidelines. However, if the time spent with the patient exceeds those guidelines by 30 minutes, the visit is still eligible for prolonged service reimbursement.

Again, documentation is crucial. Although prolonged service codes allow for higher reimbursement, the neurologist must be able to properly justify their use.