Oncology & Hematology Coding Alert

Key: Watch the clock and add up all the time spent on one calendar day.

Oncology practices may require to report prolonged services for extended patient visits. Not only is the evaluation extensive, but the provider may be spending time counseling the patient to provide treatment options and potential outcomes to help them cope with the stress of being diagnosed with cancer. Treatment planning can be a complex and time consuming task. Make sure you are reporting all the efforts that your billing provider renders.

Next time the physician performs an E/M service and spends more time than usual, you may be able to claim for this additional time and effort spent if it is appropriately documented. Look to the following add-on prolonged service codes to report the added time:

• +99354 (Prolonged evaluation and management or psychotherapy service[s] [beyond the typical service time of the primary procedure] in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service])
• +99355 (...each additional 30 minutes [List separately in addition to code for prolonged service]).

"Using these codes indicates the added visit time was in an outpatient hospital clinic or physician office setting," says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Managing Director of Pinnacle Enterprise Risk Consulting Services, LLC ("PERCS"), a division of Pinnacle Healthcare Consulting. "Additional time, when spent in these settings may only be reported only when it is spent by the billing provider face-to-face with the patient."

Do Not Lose Focus on High Level E/M Codes: Do not be mistaken. Prolonged care services can be reported with any level of E/M code, 992101-99215, not just the highest of these categories; 99205 (Office or other outpatient visit for the evaluation and management of a new patient...) or 99215 (...an established patient...) for office services.

Fact: You can report prolonged care services with any level of E/M code.

"Begin by levelling the E/M service using the 1995 or 1997 E/M Documentation guidelines," Loya says. "Then identify the total time of the visit noted. If that time exceeds the typical time of the visit, using the CPT^® code definition, then you may add the prolonged service code(s) that support the additional effort. Remember, the visit not should also provide an explanation why the additional time was necessary during the visit. A summarization of the purpose and result should be adequate."

Example: The E/M code 99203 (...a new patient...) typically applies to visit lasting 30 minutes. In order to report extended time, you will have to look at the total time spent and then report +99354 and possibly also +99355 according to the CPT^® time rules based on the time delivered.

Follow these three key tips to better understand whether or not you can report prolonged care codes in a particularsituation and, if so, what codes you need to report depending on the duration of the session.

Tip 1: Go by the Clock for Prolonged Services

When reporting prolonged services in addition to an E/M code, you will need to count the time your clinician spent face-to-face with the patient to analyze whether you can report the prolonged service codes. If you look at the descriptor of the add-on prolonged services code, +99354, notice the time duration in the definition indicates the "first hour" of service. "This means that the prolonged service is reported for the first hour AFTER the typical time of the code was met; however it doesn't mean that you may not report the code if less than an hour was provided,"

Loya says. Below are the CPT^® requirements for assigning prolonged services based on the time code CPT^® concept:

Use a minimum of 30 minutes: Your provider must have documented necessary time spent with the patient a minimum of 30 minutes longer than the typical time assigned by the CPT^® code definition of the E/M you would otherwise be reporting. For example, you may read that a patient visit qualified for CPT^® 99214, which has a typical time assigned by AMA of 25 minutes. In this case, your provider needs to spend minimum of 55 minutes with the patient to begin billing prolonged service codes.

"Prolonged services of less than 30 minutes are not separately reportable," says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. "Per CPT^®, prolonged services of less than 30 minutes beyond the typical time are part of the E/M code that you are otherwise reporting for the encounter."

For 30 to 74 minutes: You can report +99354 when the extended E/M service lasts between 30-74 minutes longer than the typical time of the E/M code you are otherwise reporting.

For 75 to 104 minutes: You report the add-on code +99355 in addition to +99354 when the session lasts between 75-104 minutes.

Beyond 104 minutes: For every 30 minutes of extended duration beyond 104 minutes, you report an additional unit of +99355.

Note: Remind physicians and other billing providers to document the time spent with the patient for E/M service and reason for any extended time to support the codes.

Tip 2: Collate total Time on A Calendar Day

Your physician needn't perform the prolonged E/M continuously at any point on a single day. The prolonged E/M may be done in split sessions. In this case, you can claim for the total additional time spent on a single calendar date.

Here are two key rules that you should follow:

• Report the base add-on code, +99354, only once for the patient on one calendar date of service for prolonged care services.
• Combine all the time spent in the various sessions throughout the day and calculate total time before you can report +99354 and the additional unit(s) of +99355.

Caution:  Do not report the add-on code, +99355 without reporting the base add-on code +99354 for the first 30-74 minutes of prolonged services. Based on the rule for add-on codes, since 99355 is added-on to 99354, both add-on codes must be reported in addition to the E/M service performed in order to describe prolong services that exceed the base E/M duration beyond 74 minutes.

"If that explanation is confusing, remember you may not report these time-based codes unless you meet a minimum of half way through the total time of the code," Loya says. "Therefore, if the visit was 75 minutes beyond the E/M code typical time, you would report +99354 for 60 minutes of that time and +99355 for the remaining 15 minutes (60+15=75) since the remaining time was at least half way into the next time increment that can be reported."

Tip 3: Check and Complete Documentation

When submitting a claim for prolonged services, more than just the time your physician spent must be documented. For assured payment, the physician (or other qualified billing health practitioner) needs to also describe the services provided supporting the medical necessity of the additional time. Make sure your documentation is complete with these essential facts.

Remember only face-to-face services qualify as additional time in the outpatient/office setting: You can submit the prolonged care service codes, +99354 and +99355, only when your clinician is performing the E/M service face-to-face with the patient. Time spent by the practitioner that was not face-to-face (i.e. if your physician spends time in the absence of the patient in reviewing some records, engages with and consults with other clinicians about the patient's condition), must not be added to the time reported.

Note: If you check the descriptor of the code codes +99354 and +99355, you can confirm that the codes apply to only 'direct service.'

What can do you for non-face-to-face services? You have a different set of add-on codes that you can try to report for prolonged services that your physician performed when they are not face-to-face with the patient. These add-on codes are:

• +99358 (Prolonged evaluation and management service before and/or after direct patient care; first hour)
• +99359 (...each additional 30 minutes [List separately in addition to code for prolonged service]).

As with face-to-face prolonged care services, you should report the add-on code +99358 for the first hour of non-face-to-face services that your physician provides to the patient and then report +99359 for every additional 30 minutes of service beyond the first hour using the same time-based code logic described above.

Caveat:  Many payers do not provide coverage for non-face-to-face prolonged care service codes, +99358 and +99359. Check payer policies and coverage guidelines to see if these services are covered before you report these codes. The requirement of face-to-face time for CMS coverage is applicable E/M services in an outpatient clinic or office setting.

Find out what Medicare says: Medicare is one of the payers that has historically not paid separately for codes +99358 and +99359, considering payment for the codes "bundled" with the payment Medicare makes for other services. However, in the proposed rule for the 2017 Medicare physician fee schedule, the CMS proposed to begin paying for these codes in 2017. You can access the proposed rule online at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1654-P.html.

Another update: On November 1, 2016, the CMS released its final rule Hospital Outpatient Prospective Payment Changes for 2017. You can access this rule on: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-11-01-3.html.

Editor's note: Read more about the rules for using +99356 and +99357 for observation and inpatient hospital services in the future issues of the Oncology Coding Alert.