Neurology & Pain Management Coding Alert

Coding for prolonged services can be intimidating, but there should be smoother sailing ahead thanks to upcoming changes from Medicare. Find out what's in store so you can capture every dollar your practice earns.

For office or outpatient services, your face-to-face prolonged service coding options are +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]) and +99355 (... each additional 30 minutes [list separately in addition to code for prolonged physician service]).

Remember: Prolonged service codes are add-on codes, and you must report them alongside E/M services. Do not report prolonged service codes alone, and never attach them to procedure codes. Tip: Recent CMS Transmittal 1490 includes a list of companion codes for 99354 and 99355 (http://www.cms.hhs.gov/transmittals/downloads/R1490CP.pdf).

Watch the clock: CPT sums up the time requirements for 99354 and 99355 in the following way:

Update: For Medicare, the provider must document the visit start and end times in the medical record with the date of service, according to Transmittal 1490, effective June 2, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, with MJH Consulting in Denver.

Notice that you should not report prolonged services separately when they total less than 30 minutes for the day, according to both CPT guidelines and Transmittal 1490.

Example: A neurologist takes 25 minutes to complete a level-three E/M service on an established neuropathy patient. Code 99213's descriptor (Office or other outpatient visit for the evaluation and management of an established-patient -) says, "physicians typically spend 15 minutes face-to-face with the patient and/or family."

You should not report a prolonged service code, because the 25 minutes the neurologist spent with the patient minus the typical 15 minutes equals 10 extra minutes. The neurologist did not meet the 30 extra minutes required to report a prolonged service.

Red flag: When you choose an E/M code based on time, prolonged service rules have always been different.

And Transmittal 1490 clarifies that for prolonged services with E/M codes based on counseling and/or coordination of care (time-based), "the time approximation must meet or exceed the specific CPT code billed (determined by the typical/average time associated with the evaluation and management code) and should not be -rounded- to the next higher level," Hammer says.

Translation: If the E/M service level is based on time spent in counseling and coordination of care (CC), the total face-to-face time -- minus the prolonged service "extra" face-to-face time -- has to meet or exceed the threshold for that level time, she says. You can't "round up" at a halfway point as you can with some other time-based codes (e.g., physical therapy codes), Hammer says.

She cites the following examples:

Example 1: A patient sees your neurologist with a total face-to-face time of 34 minutes. The established office visit level is based on time spent in CC.

Per Medicare, you can't "round" a level-four service -- 99214 (Office or other outpatient visit -) -- up to a level-five service such as 99215 (Office or other outpatient visit -) because the service doesn't meet the "threshold" of 40 minutes, Hammer says.

She says that this is true regardless of the fact that the amount of face-to-face time -- 34 minutes -- is at a point more than halfway between the times typically associated with these codes (25 minutes for 99214 and 40 minutes for 99215).

Example 2: Another patient sees your neurologist with a total face-to-face time of 65 minutes. Again, the established office visit level is based on time spent in CC. In this case, you meet the criteria for the amount of time required for billing 99215 (40 minutes).

But the actual face-to-face time (65 minutes) less the 40 minutes required for 99215 leaves you with 25 extra minutes, Hammer says. She notes that this does not meet the required threshold of 70 minutes -- or the "99215 threshold + 30 minutes" -- for you to bill 99215 plus 99354.

Bottom line: When you determine the level of service based on time spent in CC, you may bill prolonged services only if the total time meets the threshold of the highest level's typical time plus 30 minutes, Hammer says. "This would not be the case if the level of service is based on the three key components," she adds.

CPT designed prolonged services codes for physicians who spend 30 minutes more than the set time limit for a given E/M service, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa.

Prolonged service codes 99354-99357 require "face-to-face" patient care, but that doesn't mean the time must be continuous. The encounter "doesn't have to be one long face-to-face session," Falbo says.

Example: A neurologist visits a patient in the morning and, upon reviewing all of the patient's clinical information, decides that the patient needs another diagnostic study. The patient leaves to get the test and comes back that afternoon to discuss treatment options with the neurologist, who reviews the test results.

You may be able to report a prolonged service code in this case, even though the time the neurologist spent with the patient wasn't continuous, Falbo says.

You must know where the neurologist performed the prolonged service to choose the proper code.

Example: The neurologist performs a level-five E/M service that takes 75 minutes.

Level-five established patient E/M services typically take 40 minutes, so you should include a prolonged service code with the E/M code on this claim for the additional 35 minutes. In the office or outpatient setting, your claim should include the following:

- 99215 (Office or other outpatient visit ...) for the office visit
- 99354 for the prolonged service time.

If, however, you are reporting this scenario in an inpatient setting, use the following:
- 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a detailed interval history, a detailed examination, medical decision-making of high complexity) for the E/M service
- +99356 (Prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service -; first hour [list separately in addition to code for inpatient evaluation and management service]) for the prolonged service time.

Codes: When reporting inpatient prolonged services, use 99356 for the first hour of outpatient prolonged service time and +99357 (... each additional 30 minutes [list separately in addition to code for prolonged physician service]) for each additional half-hour.

Smart move: The Medicare Physician Fee Schedule shows that the prolonged services codes pay about $90 each (http://www.cms.hhs.gov/pfslookup/), but not all payers cover prolonged services. Falbo advises calling your payers and asking for their policies on prolonged services in writing.