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Oncology & Hematology Coding Alert

Extra E/M Time Not Always a Prolonged Service

Published on Sun Mar 20, 2005

Some chemo patients may need more time to review materials

When your oncologist spends 80 minutes counseling a patient during what was supposed to be a level-four evaluation and management service, can you report a prolonged service code?
 
The answer: It depends on the types of services provided. If the oncologist spent the extra time on counseling, you should use time as a controlling factor when choosing the E/M level. However, if the visit was extended because the patient needed extra time to review treatment literature, a prolonged services code may be appropriate.

Modifier -21 Can Trump Prolonged Service

Before even considering prolonged service codes, you need to know a couple of vital rules. First, these codes are designed for physicians "who spend an inordinate amount of time, specifically 30 minutes, greater than the AMA's stipulated time limit for a given level of E/M service," says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa.
 
Translation: If the oncologist takes 10-15 minutes longer than normal to complete a level-three E/M service on an established skin-cancer patient, you should not report a prolonged service code. Instead you should:
 

  •  report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity) for the service.
     
  •  append modifier -21 (Prolonged evaluation and management services) to 99213 to account for the extra time.
     
    Modifier -21 note: Including modifier -21 on the claim will not result in any extra reimbursement. The modifier will, however, show the payer that you are concerned with coding everything down to the final detail.
     
    You must also remember that prolonged service codes are add-on codes, so they must be tagged to E/M services, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J. Do not report prolonged service codes alone, and never attach them to procedure codes.

    Prolonged Service Codes Depend on Setting

    You must know where the oncologist performed the prolonged service, or the claim could go out with the wrong codes.

    Example: A stomach-cancer patient reports for an E/M service prior to an intense chemotherapy regimen. The oncologist performs a level-five E/M service that takes 45 minutes, then stays in the room with the patient while he reviews chemotherapy education literature for another 37 minutes. Level-five established patient E/M services typically take about 40 minutes, so a prolonged service code should accompany the E/M code on this claim. The claim should include: 

  •  99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history, a comprehensive examination, and medical decision-making of high complexity) for the office visit.
     
  •  +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]) for the prolonged service time. 

    When reporting prolonged services, use 99354 for the first hour of outpatient prolonged service time and +99355 ( ... each additional 30 minutes [list separately in addition to code for prolonged physician service]) for each additional half-hour for outpatients.

    Exception: If, however, the above prolonged service occurred in an inpatient setting, use:
     
  •  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.

    When reporting prolonged services in a hospital setting, 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.

    Guidelines: Since a nurse usually conducts the type of patient education in the above example, be sure the oncologist actually provided the care; otherwise, you cannot report a prolonged service code.

    Also, when time is a key factor in coding the level of E/M service, "then the prolonged services codes should only be used in addition if the service has exceeded 30 minutes beyond the highest level of E/M in the appropriate category," according to CPT Assistant, September 2000. That means you could not have reported prolonged services in the above example if: 

  •  the oncologist did not provide patient education, or
     
  •  the oncologist did not provide E/M services at the highest level possible for the code set.

    Who Pays for Prolonged Services?

    All payers do not reimburse for prolonged services, so if you're not sure whether your carrier accepts the codes, do not report them. In Falbo's area, "Medicare pays for them, but the other [payers] are case-by-case," she says.

    However, not all Medicare carriers will reimburse for prolonged service codes. Just ask Sue Coffee, office administrator at Central Illinois Hematology Oncology Center in Springfield, Ill. "Commercial insurance pays [for prolonged services], and some Blue Cross Blue Shield [carriers] pay. It is a noncovered charge for Medicare," she says.

    Good advice: With all the disparate policies on prolonged service payment - even among Medicare carriers - it might behoove you to hit the phone and call some payers before reporting prolonged services. "Query your top payer classes [on prolonged services] and obtain something in writing as an addendum to their managed- care contract," Falbo says.

    Face-to-Face Time Is Cumulative, Not Continuous

    All of the prolonged service codes 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," Falbo says.
     
    Example: An orthopedic oncologist visits a patient in the morning and, upon reviewing all the patient's film, decides that the patient needs another hand x-ray. The patient leaves to get the x-ray, and comes back that afternoon, whereupon the oncologist reviews the x-ray and discusses treatment options. 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.

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