Neurosurgery Coding Alert

Question: If the neurosurgeon spends a prolonged amount of time with the patient during a patient visit and documents this, can we charge for this additional time? If so, how would we bill this?

Alabama Subscriber

Answer: Spending time doing what? What sort of visit is this? To use the prolonged services codes (+99354, Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; 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]), you need to:

• bill an E/M code that has a time component (such as 99201-99215, Office or other outpatient visit ...),

• have documentation for a prolonged service that is more than 30 minutes beyond the typical time listed for the code you billed,

• have the medical need clearly stated for the prolonged service.