Neurology & Pain Management Coding Alert

Prolonged services codes (99354-99359) are a good option when seeking reimbursement for significant extra time spent caring for patients. For example, when treating children, neurologists often need to spend much more time, and a higher-level E/M code may not fit the circumstances, resulting in inaccurate coding.

Billing for Prolonged Services

You need to remember that the prolonged services codes are add-on codes, which means they cannot be billed on their own but must accompany another E/M service, says Kim Rivera, general manager and co-owner of Sound Management and Billing Services Inc., an organization that bills for neurologists and other specialties in Seattle. Because these codes are time-based, they can be added only to E/M services that have a time component or reference time built in, such as hospital admissions, inpatient follow-up care, consults or office visits.

To bill for prolonged services, the neurologist must document in the patients medical record the additional time spent. He or she also needs to report what occurred and why the visit went beyond the allotted time.

There are two sub-categories of prolonged services: with direct (face-to-face) contact (99354-99357) and without direct (face-to-face) contact (99358-99359).

For example, 99354-99357 can be used when a physician performs a level-four, new patient evaluation (99204) on a child with cerebral palsy (343.9). However, because of the childs fear and inability to communicate with the neurologist, the visit takes 80 minutes instead of the normal 45 minutes. In this case, the doctor would bill 99204 to cover the first 45 minutes of the visit and 99354 for the additional 35 minutes.

Codes 99358-99359 can be used when a neurologist performs a level-four, established patient visit (99214) on a patient with Alzheimers disease (331.0). After the
25-minute exam, the physician spent 45 minutes with the patients daughter to review complex, detailed medical reports and completes a comprehensive treatment plan. In this case, the neurologist would bill 99214 to cover the first 25 minutes and 99358 for the additional 45 minutes.

According to CPT 2001, 99358-99359 are used when a physician provides prolonged service not involving direct care that is beyond the usual service in either the inpatient or outpatient setting. Claims using these codes are rarely paid, says Melody Mulaik, MSHS, CPC, president and co-founder of Coding Strategies Inc., an Atlanta-based coding and reimbursement firm that supports more than 500 physicians nationwide.

Do Not Bill with Emergency Department Codes

Some coders have had claims denied when billing a prolonged services code as an add-on to an emergency department (ED) visit (99281-99285). Because the ED codes have no time component or reference time. There is no way to indicate what was prolonged, so these claims will be denied or pended.

To bill for extra time spent in the ED, use the prolonged services codes with the admit code (99221-99223). For example, a patient presents in the emergency room with trauma after a fall, and the neurologist determines that he or she must be admitted because a concussion (850.9) is suspected. The neurologist performs a full workup in the emergency room and then does a level-two admission (99222, initial hospital care, per day).

For this patient, if the total time the physician has documented is equal to or exceeds 30 minutes beyond the reference time for the admit, the first hour of prolonged inpatient services (99356) may also be billed. The neurologist did a level-two admit, which has a reference time of 50 minutes. If 81 minutes were spent with the patient within a 24-hour period and can be documented between the ED chart and the admission chart (81-50=31), both 99222 and 99356 can be billed.

Document Time Spent with Patient

Prolonged services are one of three E/M code categories that are entirely time-based. (Critical care and care plan oversight are the other categories.) This means that the regular E/M categories history, exam and medical decision-making do not apply when billing for these services. Instead, the amount of time spent face-to-face determines the code.

Office visits also include reference times when counseling the patient or coordinating care comprises more than 50 percent of the visit. For example, during an office visit, an established patient is told about a Parkinsons disease (332.0) diagnosis. The neurologist may spend 70 minutes with the patient counseling and/or coordinating care. Even with a level-five established patient code (99215), only the first 40 minutes of the encounter are included. The remaining 30 minutes may be billed using 99354. Both 99215 and 99354 would be linked to the Parkinsons disease diagnosis.

Documentation needs to include what was discussed and any other pertinent clinical information, such as the patients vitals, blood counts and why counseling was necessary or what the doctor did to coordinate the patients care. A simple notation that 45 more minutes were spent is not sufficient.

To charge for each additional half-hour of prolonged services (99355 for outpatient and 99357 for inpatient), at least 15 minutes of the additional 30 minutes claimed must be documented. With any time-based code, whether critical care or prolonged service, once 30 minutes of the first hour (30-74 minutes) is reported, youve met the requirements for the first hour, Rivera says. The same applies for the next 30 minutes, she notes. Once 75 minutes of face-to-face contact is documented, the neurologist can charge for another half-hour.

Note: Neurologists should be consistent and document start and stop times, although they arent required.

Billing for Both Direct and Without Direct Contact

Often, a doctor does not spend his or her entire time with the patient but is still actively involved in treatment. For example, when a neurologist admits a patient (99223), the 70-minute reference time for a level-three hospital admission includes counseling or coordination of care over and above the 50 percent of the encounter. The time includes not only face-to-face but also floor time on the unit. The documented time to support billing with 99354-99357 must be face-to-face. For instance, if the physician spent a total of 100 minutes with the patient, at least 30 minutes must be direct or face-to-face. The neurologist, therefore, should document ordering labs or consults, conferring with other physicians or staff, and evaluating results, other chart notes and reports from earlier consults. These are all part of the floor time for any inpatient service and may be counted as part of the admission. Doctors can include all those seemingly extraneous tasks if they document what they did, Rivera says. This enables the neurologist to bill a higher-level prolonged services code.

If some of the floor time included in the admission code is spent talking to the family about the patients condition, that too may be included, Rivera says. She notes, however, that encounters with family members should take place in the patients ward.

She also recommends that neurologists note in the inpatient chart that the admit is a continuation of the time already spent in the ED, although there is a separate ED chart. That way, she says, if someone reads the inpatient chart only, it can stand on its own.

Note: Because the patient was admitted, the physicians services will be coded based on the inpatient chart. The coder may never see the ED chart. Thus, it is wise to have the information necessary to justify the use of prolonged services codes in both.

Bill a Higher-level E/M Instead of Prolonged Services

Rivera explains that if the time requirements are met, you can choose to code a higher-level office visit, without the prolonged service code. By not using 99354, there is a better chance of getting paid without having to face an appeal, she says. Using the lower level for the office visit with the prolonged service code will entail careful documentation to support the care that is given.

However, you must make sure that the complexity and management of the problem meets the higher E/M level and that the time was prolonged. For example, a neurologist performed an established patient visit that was supposed to take 10 minutes and billed 99212. Unfortunately, because complications with the treatment required a comprehensive history and exam as well as highly complex medical decision-making and counseling, the visit lasted 40 minutes. Due to the additional work that the physician had to do during this visit, it would be appropriate to code it as 99215 as opposed to using a prolonged services code since the higher-level E/M requirements were met.

Modifier -21 is an Option

CPT 2001 also includes modifier -21 (prolonged evaluation and management services). Although this modifier is still in the manual, Mulaik says it is rarely used. No specific time (or reimbursement) is defined, and physicians are instructed to use it only with the highest-level E/M codes in any category.

Note: Prolonged services were added to the E/M section of the CPT manual in 1995. Some payers, such as certain workers compensation carriers, use older versions of the manual and therefore do not recognize or pay for such claims. If your prolonged services claim is denied for no apparent reason, you should appeal. If positive results are not forthcoming, contact your states department of insurance.