Ob-Gyn Coding Alert

You should be charging for all the time you spend seeing a patient. Especially in those long initial visits, says Barbara J. Cobuzzi, MBA, CPC, a physician reimbursement specialist and president of Cash Flow Solutions, Inc., of Lakewood, NJ. Most of the time when ob/gyns see patients, the time spent face-to-face with the patient falls within a typical range for the level of service being provided. This typical or reference time is reflected in the CPT manual when you select which Evaluation and Management (E/M) code to use when billing for the office visit.

But often ob/gyns spend much more time with their patients than the typical time defined by the E/M code, Cobuzzi relates. For example, a patient who has been sexually assaulted will likely require a great deal of the ob/gyns time, not only for the physical examination but for helping the patient deal with the emotional issues surrounding the assault. Other situations that would likely require a lengthy office visit would be a teenage patient who became distraught after receiving a positive pregnancy test, or a diabetic patient who did not speak English and relied on her daughter to translate details about an imminent hysterectomy.

In each of these cases, coders can request that the practice be reimbursed for the additional time that the ob/gyn has spent in face-to-face contact with the patient. This request is coded using Prolonged Services codes (99354-99355). Prolonged services are one of the most misunderstood and under-utilized coding opportunities, asserts Cobuzzi. Heres how these codes are used.

Determine the Typical Amount of
Time Allotted

First, coders must select the appropriate E/M codes for the service, since Prolonged Services codes are always used as an adjunct to other service codes. In the office setting, these codes include Office Visit codes (99201-99205 for new patients and 99211-99215 for established patients). Each of these E/M codes contains a time element, as defined in the CPT manual. Cobuzzi says these are the reference times (i.e. the typical, average amounts of face-to-face time that the physician spends with patients and/or their family members when the office visits are associated with those codes.) These times are as follows:

    New Patients	Established Patients:

99201  10 minutes	99211   5 minutes
99202  20 minutes	99212  10 minutes
99203  30 minutes	99213  15 minutes
99204  45 minutes	99214  25 minutes
99205  60 minutes	99215  40 minutes

Note: The typical time allotted for the new patient visit is slightly more than that associated with the same level visit for an established patient. This difference reflects the additional time that it takes the physician to assess a patient with whom he is unfamiliar.

Calculate the Additional Time Spent

Once you have determined the proper E/M code, and the typical time associated with it, you can compare that amount of time to the actual time that the ob/gyn has spent with the patient.

Tip: Obviously, coders need to know how long the ob/gyn spends with each patient in order to use the Prolonged Services codes. To help their coders, ob/gyns should log their times in and out of the exam room as part of their progress notes for each patient.

The clock for prolonged services starts when the visit begins, says Cobuzzi. For example, lets say your ob/gyn just spent 45 minutes in the office with an established patient. After the patient learned that she was pregnant, she burst into tears because she didnt want to have the baby. Typically, an office visit to confirm pregnancy for an established patient would be coded using 99213, which corresponds to an average face-to-face contact between the ob/gyn and patient of 15 minutes. Your physician has spent an additional 30 minutes with this patient, and should bill accordingly.

Amend with Prolonged Service Codes in
30-Minute Increments

When coding for the visit outlined above, use E/M code 99213, and then amend it with a 99354 (Prolonged Services) to reflect the additional 30 minutes of face-to-face contact. The more time that a physician spends in prolonged face-to-face contact with the patient, the more he or she can bill for that time, so long as the Prolonged Services code is used along with the Office Visit or other E/M codes.

Additional Office Time Codes

Code 99354 is used for the first time slot (30-74 minutes) over and above the typical time allotted for the visit. The code 99355 is used for the next 30 minutes over and above the allotted time, and for each additional 30-minute increment from then on in the outpatient setting.
What happens if the ob/gyn spends only an additional 25 minutes with the patient over and above the typical time allotted to that level of service? You get nothing , says Cobuzzi. Fewer than 30 additional minutes is not reported separately. This is because additional time up to 30 minutes is included in calculating the typical average work time for the E/M codes.

Tip: Although CPT also lists a modifier -21 (Prolonged Evaluation and Management services), this modifier can only be used when the highest level of code in a given category (eg, 99215) has been billed. Unfortunately, there are very few insurers who recognize this modifier.

Prolonged Services codes can be used regardless of whether the additional time is spent with the patient in a continuous manner, or if it is spent during several short periods, so long as the face-to-face contact occurs within the same 24-hour day. Codes 99354-99355 are used to report total duration of face-to-face contact within a given day.

Prolonged Preventive Medicine Services

Prolonged Services codes also can be used along with the highest level of Preventive Medicine Counseling and Risk Factor Reduction Intervention code (99404 - 60 minutes of counseling).

Remember that the 60 minutes allottable to 99404 for counseling must be subtracted from the total time that the ob/gyn spends with the patient. If after that subtraction the time spent is greater than 30 additional minutes, then a Prolonged Services code may be added to reflect that additional time. Examples of when preventive medicine services might demand prolonged face-to-face contact are HIV prevention counseling and extensive life-style counseling.

Dont Forget Your Documentation

Make sure the patients chart reflects the time spent and why, advises Cobuzzi. As with all reimbursement requests, coding for Prolonged Services must be backed up with necessary documentation, most specifically with detailed notes on precisely how much face-to-face time the physician spent with the patient and why this extra time was necessary. Preferable to total time is start and stop time, says Cobuzzi. Frequent use of the Prolonged Services codes (more than 10%) may lead to an audit, so reserve their use for the really tough circumstances.