Neurology & Pain Management Coding Alert

If the neurologist provides an extended E/M visit, you may be tempted to report prolonged services (99354). But unless he or she spends at least 30 minutes beyond the CPT reference time for the E/M level you choose, you'll be overbilling if you choose 99354-99357.

Maintain a '30 Minutes Over' Minimum

Prolonged services are a valuable reimbursement tool, but they require that you track carefully the total face-to-face time the neurologist spends with the patient.
 
To use +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient evaluation and management service]) or +99356 (Prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service [e.g., maternal fetal monitoring for high-risk delivery or other physiological monitoring, prolonged care of an acutely ill inpatient]; first hour [list separately in addition to code for inpatient evaluation and management service]) the physician must provide a minimum of a half-hour of face-to-face time with the patient in addition to the time that CPT allots for the E/M service you claim. The time need not be continuous, says Jaime Darling, CPC, certified coder for a nine-physician practice in Escondido, Calif., but it must occur on the same date of service.
 
For example, an established patient arrives unscheduled at the neurologist's office. The patient's daughter has brought him because he became disoriented and began slurring his speech while the two of them shopped at a nearby grocery store, and she's worried that her father is suffering a stroke. The neurologist takes the emergency appointment and spends 30 minutes evaluating the patient. Confident that the patient is not in immediate danger, the neurologist leaves the room to attend to another patient. He later returns and spends an additional 10 minutes with the patient before releasing him. The physician's level of documentation supports a level-four office visit (99214, Office or other outpatient visit for the evaluation and management of an established patient ...).
 
In this case, you cannot report prolonged services in addition to 99214, Darling says. The CPT reference time for 99214 is 25 minutes. The physician spent a total of 40 minutes with the patient and does not meet the requirement of at least an additional 30 minutes to report 99354. Had the neurologist spent and documented 55 minutes (25 minutes for 99214 + 30 minutes toward prolonged services) or more, however, you could claim 99354 in addition to 99214.
 
Note: You can find a complete list of "threshold times" for reporting prolonged services with individual E/M services in the last sentence of each CPT code definition, or in the Medicare Carriers Manual, section 15511.1, subsections "E" and "F."

Apply 99355/99357 for Time Beyond the First Hour

If the physician supplies prolonged services beyond an hour, you should report additional time using +99355 (... each additional 30 minutes [list separately in addition to code for prolonged physician service]) or, for inpatients, +99357, Darling says.
 
To use 99355/99357, the physician must spend at least 15 minutes of the additional half-hour of prolonged services after the initial hour of prolonged services. Therefore, the total time beyond the reference time of the primary E/M code must equal at least 75 minutes. This is true of all subsequent half-hour segments.
 
For instance, in the above example, if the visit lasted 95 minutes, the neurologist would report 99213, 99354 and 99355 (95 minutes - 15 minutes reference time = 80 minutes, or one hour and 20 minutes of prolonged services). If the total visit lasted 85 minutes, however, you would not report the additional half-hour (85 minutes - 15 minutes reference time = 70 minutes. This is only 10 minutes - not the required 15 minutes - beyond the first hour, and therefore not sufficient to report 99355). Do not downcode your E/M service (for example, to 99212) to take advantage of a lesser reference time and therefore report prolonged services. Although you will earn more by claiming prolonged services with the lower-level E/M, this is fraudulent billing.

Document Physician Time

"Documentation of time spent is the essential key to billing for prolonged service codes. Without an actual minute value stated in the physician notes, this code is not valid no matter how much time was actually spent," says Linda Laghab, CPC, a coding department manager at Children's Hospital, Los Angeles.
 
The Medicare Carriers Manual, section 15511.1, specifies that "the medical record must document the duration and content of the E/M code" to support prolonged services billing. Simply noting that the surgeon spent an extra 42 minutes with the patient is not adequate. You must justify why the time was necessary. You have to make clear in the medical record what you billed using the E/M service codes as well as what comprised the prolonged services, Laghab says.
 
Medicare does not require that the physician document start and stop times in addition to total time, but as is often the case with documentation, more is better.

Don't Forget 99058 for In-Office Emergency Care

You should report 99058 (Office services provided on an emergency basis) anytime the neurologist provides emergency care in the office, which occurs frequently with prolonged services.
 
In the example above of the patient who arrives with disorientation and slurred speech, the neurologist had to interrupt his scheduled appointments to provide office services on an emergency basis, which would warrant 99058. Not all insurance carriers pay for 99058, but if they do, reimbursement is generally reasonable.