Neurosurgery Coding Alert

Physicians and coders are reluctant to report prolonged services codes (99354-99357) because of lack of knowledge regarding the guidelines. When, for instance, is it appropriate to claim prolonged services rather than to calculate an E/M visit using time as the determining factor? Do prolonged services stand alone, or must they be reported with another E/M service? If they are reported with other E/M services, which codes apply? What documentation is necessary? Do most payers reject prolonged services claims? Clearly, the confusion surrounding these codes is legitimate. However, prolonged services are too useful to dismiss as insignificant or overly complicated.

Prolonged services are a unique category of E/M codes that describe face-to-face, physician-to-patient contact "that is beyond the usual service in either the inpatient or outpatient service," according to CPT. Such situations may occur if a patient is noncompliant or requires special attention due to a mental or physical handicap, or if the surgeon must explain complex diagnoses, treatment options or substantial lifestyle changes to the patient. Applicable codes include:

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)

99355 each additional 30 minutes (list separately in addition to code for prolonged physician service)

99356 Prolonged physician service in the inpatient setting, requiring direct (face-to-face) patient contact beyond the usual service (e.g., maternal fetal monitor-ing 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)

99357 each additional 30 minutes (list separately in addition to code for prolonged physician service).

These services are reported in addition to other physician services, including E/M services at any level, and 99355 and 99357 may be reported only in addition to 99354 and 99356.
 
Got the Time?

Prolonged services codes are time-based and may only be appended to other E/M codes that include a reference time (without this time component, there is no way to define a service as "prolonged"), advises Linda Laghab, CPC, coding department manager for Pediatric Management Group at Children's Hospital, Los Angeles. Specifically, section 15511.1 of the Medicare Carriers Manual (MCM) dictates that 99354 and 99355 may only be reported in addition to 99201-99205 and 99212-99215 (Office or other outpatient visit) or 99241-99245 (Office or other outpatient consultation). Similarly, 99356 and 99357 must accompany a claim of 99221-99223 (Hospital inpatient services), 99231-99233 (Subsequent hospital care), 99251-99255 (Initial inpatient consultations), 99261-99263 (Follow-up inpatient consultations), 99301-99303 (Comprehensive nursing facility assessments) or 99311-99313 (Subsequent nursing facility care).
 
Medicare carriers will not reimburse prolonged services unless they are accompanied by an approved "companion" code. Prolonged services cannot be billed with the following, says Cathy Klein, LPN, CPC, medical policy specialist with Health Care Excel Inc. in Indianapolis:

 

Hospital observation services
 

Observation or inpatient care services (including admissions and discharges)
 

Critical care services
 

Emergency department services (unless the physician is providing an outpatient consultation that goes beyond the typical time spent with a patient).

When you want to report the first hour of prolonged services, the reference time for the primary E/M service must be exceeded by a minimum of 30 minutes. For example, the neurosurgeon sees an established patient who has been in an automobile accident and has spinal nerve damage. The surgeon provides an E/M service that measured by the key components of history, examination and medical decision-making qualifies as a level-three outpatient visit (99213). Because the surgeon spends time discussing a proposed surgery with the patient, however, the visit requires 57 minutes 42 minutes beyond the 15 minutes allotted (per CPT guidelines) for a level-three established patient office visit. In this case, because the services provided were beyond those typically provided (requiring 42 minutes longer than usual) the neurosurgeon may report 99213 and 99354.
 
For an additional half-hour of prolonged services, the total time required beyond the reference time of the primary E/M code must equal at least 75 minutes. The physician must account for at least 15 minutes of every additional half-hour billed. In the above example, if the visit lasted a total of 95 minutes the neurosurgeon 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 only lasted 85 minutes, however, the additional half-hour is not allowable (85 minutes - 15 minutes reference time = 70 minutes, or only 10 minutes not the required 15 minutes beyond the first hour)
 
If warranted, physicians may report multiple units of 99355 or 99357. For instance, using the above example, a two-hour visit would be reported 99213, 99354, 99355 x 2 (120 minutes - 15 minutes reference time = 105 minutes, or one hour plus 30 minutes plus 15 minutes.)
 
Note: A complete list of "threshold times" for reporting prolonged services with individual E/M services is in the MCM, section 15511.1, subsections "E" and "F."

Time counted toward prolonged services must occur on the same date of service, but does not need to be continuous, Laghab says. The surgeon may consult with a patient in the hospital, spend 30 minutes discussing his or her condition, leave to perform regular rounds, and return to the original patient for another 40 minutes of counseling. The time spent with the patient before and after the surgeon conducted rounds can contribute toward prolonged services.
 
To count effectively, however, all time must be documented. "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," Laghab explains.
 
The MCM, section 15511.1 instructs carriers to "Advise physicians that to support billing for prolonged services, the medical record must document the duration and content of the E/M code billed ... " Simply noting that an extra 42 minutes were spent with the patient is not adequate. The extra time must be justified. "It must be clearly evident in the medical record what was billed for using the E/M service as well as for the prolonged service," Klein says.
 
Medicare does not require that the physician document start and stop times, but as is often the case with documentation, more is better.
 
Prolonged services must also be provided face-to-face (and documented). Unlike the care plan oversight codes (99374-99380), prolonged services do not apply if the surgeon spends time arranging treatment in the patient's absence or discussing a patient's condition with other healthcare professionals. Even if a patient spends four hours in the physician's office, if the physician sees the patient face-to-face for only 20 minutes, prolonged services are not billable.
 
Time-Based E/M or Prolonged Services?

CPT specifies that if counseling and coordination of care consume 50 percent or more of an E/M visit, time may be used as the determining factor when selecting an appropriate E/M level. How, then, do physicians and coders decide when to report prolonged services and when to use time to justify a higher E/M level? For instance, is the proper coding for a 50-minute established outpatient visit in which 35 minutes were spent on coordination and care 99215 or 99213, 99354? Arguably, either solution accurately describes the services provided.
 
Unfortunately, neither CPT nor CMS offers guidance in this regard, and coding experts differ in their opinions. Generally, it is best (financially and for coding accuracy) to assign E/M levels according to the key components of history, examination and medical decision-making. Then, if 30 minutes or more are spent on counseling and coordination of care, access the prolonged services codes. If fewer than 30 additional minutes were spent face-to-face with the patient, but counseling and coordination of care exceed 50 percent of the time allotted to the visit, you may choose to code a higher E/M level based on time. As long as the physician does not attempt to misrepresent the services provided, he or she deserves to be reimbursed for additional time spent with a patient.
 
For instance, a new patient presents seeking surgical relief from chronic carpal tunnel syndrome in both wrists to the neurosurgeon for an outpatient consultation. Based on the components of history, examination and medical decision-making, the visit warrants a level-two visit (99242). However, the surgeon spends an additional 40 minutes (beyond the 30-minute reference time) discussing treatment options with the patient. In this case, report the consult (99242) and one hour of prolonged services (99354).
 
If, the same patient presents for the same consult but requires only 20 additional minutes (again, beyond the 30 minute reference time for 99242) with the neurosurgeon, prolonged services cannot be billed. If the total time of the consult (50 minutes), 30 minutes (over 50 percent) were spent on counseling and coordination of care, the surgeon may use time as the key component when assigning the E/M level. Although the components of history, exam-ination and medical decision-making make the visit a level-two consult, using time as the determining factor the neurosurgeon can report a level-three code (99243).
 
Although physicians may prefer not to be paid "by the clock," getting reimbursed for the work they do sometimes requires it. Because physicians don't always know when a patient is going to require this extensive care at the outset of a visit, it's a good idea to note the date and time any encounter begins.

CPT includes two codes for prolonged services without direct patient contact: 99358 (Prolonged evaluation and management service before and/or after direct [face-to-face] patient care [e.g., review of extensive records and tests, communication with other professionals and/or the patient/family]; first hour) and 99359 (... each additional 30 minutes). These are also add-on codes and should not be reported as the only service, Klein says.
 
Medicare has not assigned a relative value to these codes, and instructs payers not to reimburse for these services, reasoning that "payment for these services is included in the payment for direct face-to-face services that physicians bill" (i.e., the services are considered "bundled" into any E/M services provided). Therefore, you cannot bill the patient even with an advance beneficiary notice (ABN). You may report these codes for the sake of accuracy, but do not expect reimbursement from Medicare payers.
 
Note: Some third-party payers may recognize non-face-to-face codes. Check with your payers for guidelines.