Oncology & Hematology Coding Alert

When an oncology-related visit takes longer than normal, codes +99354-+99355 used to describe a prolonged visit with face-to-face physician-patient contact are appropriate as long as the circumstances and services that resulted in extra time spent can be proven. In contrast, these codes should not be used for an extended visit that includes routine services.

There has to be face-to-face contact with the patient where the disease is discussed, says Dianna Hofbeck, RN, CCM, HCFE, RN CCM, ACFE, president of North Shore Medical, a billing, coding, collection and healthcare consulting firm in Atlantic City, N.J. You have to document the exact amount of time and the reason behind it.

The codes can be used either to report added time as a result of unforeseen circumstances, such as the discovery of a new condition, or for additional visit time beyond what the physician normally spends with a patient, says Riise Cleland, president of Oplinc Oncology Services, an oncology coding consulting firm in Lawton, Okla. An example would be counseling before and after a chemotherapy visit.

You can use prolonged service codes under the following circumstances:

They may be added to any other physician service, including an E/M;

They should be used to report the total duration of face-to-face contact, even if the time is not continuous;

They may be used only once per date of service, even if the time spent with the physician was not continuous.

If the prolonged service was less than 30 minutes, then +99354 is not separately reportable and the service should be included with the E/M.

While +99355 is used to report time spent with the patient beyond the first hour, it must be between 15 and 30 minutes. If the time is less than 15 minutes, then +99355 should not be reported in addition to +99354. Subsequent uses of +99354, when prolonged service extends beyond 90 minutes, for example, should be used just as it would be for service beyond one hour. If it does not extend beyond one hour, 45 minutes, then +99355 can only be reported once. If time extends beyond one hour, 5 minutes, then +99935 can be reported twice.

Justifying Prolonged Service Codes

An office visit for a follow-up on chemotherapy treatment may take an average of one hour, including the examination and a problem-focused history. On occasion, this type of visit may run longer, perhaps 45 minutes to one hour longer. On the surface, this may seem like an appropriate time to assign +99354.

However, deciding whether to use +99354 or +99355 is not as objective as you would think. Rather than using time as the determining factor, you should consider the surrounding circumstances instead.

As long as the physician has reported what occurred, the record should detail the encounter and explain why extra time was needed. Specifically, documentation should include:

New diagnosis codes. This can be an indication that a new condition was discovered that required more time.

Test orders that fall outside the norm. Tests, such as a blood test, may also prove that the physician noticed a new condition or was addressing a concern that required extra time.

Unusual or severe side effects from chemotherapy or chemotherapy-related drugs. Again, indications that the patient was in need of care beyond the normal scope of visits that were similar in nature.

Lengthy counseling. Addressing the psychosocial aspect of patient care is an appropriate reason to report prolonged service. One example might have the patient voicing concern about the effectiveness of his or her treatment or anxiety that requires the physician to go over the plan.

While time is not the overriding factor, it can be used as a benchmark, Cleland says. Codes 99211-99215 used to report office or outpatient visits are primarily governed by the three components of E/M services history, exam and medical decision-making. The CPT manual, however, associates typical amounts of time associated with each level of E/M service. For example, 25 minutes is the normal amount of time physicians spend with patients who meet the requirements associated with 99214.

Cleland says the following three questions should be asked to determine whether to use prolonged visit codes:

1. Does the current E/M service meet the requirements set by Medicare? For example, if 99214 is assigned, were two of the following performed: detailed history; detailed examination; medical decision-making of moderate complexity?

2. Did the amount of time exceed 55 minutes (25 minutes typical to a 99214 visit plus an additional 30 minutes required to report the first hour of prolonged service, +99354)?

3. Were additional services provided or was the extra time the result of a slower pace?

According to Hofbeck, the key word is acuity the seriousness of the patients condition at the time of the visit. Many visits in oncology practices can be described as routine, that is, the same types of services vary little from one patient to the next. What does vary, however, are reactions to drugs or patients anxiety. Physicians need to show the severity of these factors by including a detailed narrative in the record.

A Few Words About Face-to-Face

There is debate over whether face-to-face time is the total of the actual time the patient is in the presence of the physician, or whether it is represented by the start of the additional time to the end, regardless of whether the physician was present the whole time.

Cleland advises practices to take a literal approach to time assignment. If the physician spends 30 minutes at the beginning of a visit on counseling, 30 minutes of care is then provided by a nurse outside the view of the oncologist, and then the physician spends an additional 30 minutes providing more counseling, the amount of prolonged face-to-face time is one hour, says Cleland.

Another related item to consider is that CPT includes prolonged service codes for physician services that are without face-to-face time, +99358-+99359. Both Hofbeck and Cleland agree that these should not be used to describe services provided by a nurse. Instead, they should be used for the examination of records and tests that require an excessive amount of time.

Cleland uses the example of a new patient. The physician conducts an exam and 99203 is coded. The patient, however, brings his current medical record, which must be reviewed by the physician after the visit. This should require complex medical decision-making, and thus the use of +99358-+99359, Cleland says.