Oncology & Hematology Coding Alert

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

With the PHE for COVID-19 and social distancing, your oncologist still may have extended patient visits. Not only can the evaluation be extensive, but the provider may be spending time counseling the patient to provide treatment options and potential outcomes to help them cope with dispelling myths from the media, the stress of the current environment, their increased health risk and being diagnosed with cancer. In addition, the patient’s treatment planning can be a complex and time-consuming task.

Make sure you are capturing all the time, complexity and full scope services rendered in the supporting documentation with prolonged services codes.

Note: This article’s advice is pertinent for 2020 claims. Prolonged services will change in 2021, so look for more information in upcoming issues of the Oncology Coding Alert.

The next time your oncologist performs an Evaluation and Management (E/M) service and spends more time than typically spent for the parent E/M code, you may be able to claim for additional time and effort when 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, Associate Partner, Pinnacle Enterprise Risk Consulting Services LLC. “Additional time, when spent in these settings may only be reported by the billing provider whose time is spent face-to-face with the patient. And remember, ‘direct patient contact’ in the office setting means face-to-face.”

Do Not Lose Focus on High Level E/M Codes: Prolonged care services can be reported with any level of E/M code, 99201-99215, 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 the total time exceeds the typical time of the visit, using the CPT^® code definition, then you may add the prolonged service code(s) to support the additional effort if it exceeded the typical time of the E/M supported by leveling was exceeded by at least 30 minutes. Remember, the visit note should also provide an explanation as to 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 +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 particular situation 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 the codes are reportable. 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 the prolonged service is reported for the first hour AFTER the typical time of the code was met; however it doesn’t mean 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 at 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 must spend a minimum of 55 minutes with the patient face-to-face 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 exceeding 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 halfway 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.”

Lastly, if time is the basis for reporting the E/M that would not otherwise meet the leveling, then you’ll report the highest code in the category and the prolonged service must exceed the typical time of the highest code, and be at least 30 minutes beyond the typical time to meet the threshold to report the initial prolonged service code. For example, your physician sees an established patient and the visit involved coordination and counseling and the level was determined on the time spent. Since the highest level in the outpatient established code category is 99215, a total of 40 minutes would be required to support 99215. Then to report +99354, an additional 30 minutes (or time exceeding 70 minutes) is required in order to meet the threshold to report 99215 and +99354.

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), through the end of 2020 must not be added to the time reported.