Oncology & Hematology Coding Alert

CPT offers you the chance to report extra time that your oncologist spends with a patient. But be sure you-ve got a calculator handy and a grasp on the prolonged services coding rules before you get started.

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]).

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

< 30                                         Don't report separately

30-74                                        99354 x 1

75-104                                      99354 x 1, 99355 x 1

105-134                                     99354 x 1, 99355 x 2

135-164                                     99354 x 1, 99355 x 3

165-194                                     99354 x 1, 99355 x 4

Remember: Prolonged service codes are add-on codes, and you must report them alongside E/M services, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J.

In other words: Do not report prolonged service codes alone, and never attach them to procedure codes.

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

- Example: An oncologist takes 25 minutes to complete a level-three E/M service on an established skin-cancer 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 oncologist spent with the patient minus the typical 15 minutes equals 10 extra minutes. The oncologist did not meet the 30 extra minutes required to report a prolonged service.

Red flag: When you choose your E/M code based on time, prolonged services rules change. Get up to speed with "Time-Based E/M? Take Care With Prolonged Services" on page 77.

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 to 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," explains-Falbo.

Example: An oncologist 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 oncologist who reviews the test results.

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

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

Example: A patient with stomach cancer reports for an E/M service prior to a chemotherapy regimen. The oncologist 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 the prolonged services codes pay roughly $90 each, but not all payers cover prolonged services. Falbo advises calling your payers and asking for their policies on prolonged services in writing.