Oncology & Hematology Coding Alert

Question: Our physician provided a one hour E/M service, most of which was spent on counseling, so we reported 99215 and one unit of +99354. An outside auditor came to our practice, said we should not have reported +99354, and told us to write our payer and give back the reimbursement we received for this extra charge. Is this accurate?

Ohio Subscriber

Answer: Your auditor is correct. You can add +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour) only if your physician spent an additional 30 to 74 minutes beyond the typical time of 40 minutes allotted for 99215. In your case, the physician spent a total of 60 minutes on the service. He'd need to spend at least 70 minutes total (40 minutes plus at least 30 minutes) to report 99215 with +99354.

Example: Your physician spends 75 minutes face-to-face visiting with a 79-year-old patient who has several comorbid conditions. The patient's son is present, as well. The doctor goes over the problems and counsels the family on potential solutions with the patient present. "Counseling" is an important word to use as it helps to support coding based on time.

In this example, you'll report one unit of 99215 to cover the first 40 minutes, plus one unit of +99354 for the extra 35 minutes of face-to-face prolonged services.