Oncology & Hematology Coding Alert

Question: Our oncologist wants to report 99214 in addition to prolonged service codes for another hour of care. But the oncologist provided the extra hour at different settings. Can we still report 99354?

Tennessee Subscriber

Answer: Typically, you can report prolonged services (99354-99355) for additional time the physician provided at different settings. CPT doesn't require that your physician perform prolonged service continuously. Even so, your physician should document all time spent with the patient. The medical record must document the duration and content of the E/M code to support billing prolonged services, according to the Medicare Carriers Manual.

For example, the oncologist sends a patient for x-rays (70010-76499) and computed tomography scans (76070, Computed tomography, bone mineral density study, one or more sites; axial skeleton [e.g., hips, pelvis, spine]). Afterward, the physician and the patient discuss results from interpretation x-ray films and a treatment plan. Overall, the visit lasts 85 minutes.

For the first 25 minutes, your physician bills 99214 (Office or other outpatient visit ... established patient ...), and for the extra hour, he bills +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]).

In this instance, you could correctly report 99214 and 99354 even though radiological studies broke up the visit.

Remember that physicians don't have to submit documentation along with the claim for prolonged service codes, according to CMS. But you should have the documentation available in case a Medicare carrier targets your physician for medical review.
 
Also, you should document the time the physician spent with the patient. Remember that you can add only time spent in face-to-face care. For instance, you can't bill for professional discussions concerning a patient's care. The documentation should include the start and stop times for the prolonged care.