Oncology & Hematology Coding Alert

Question: Are there E/M codes I shouldn't report alongside prolonged services codes 99354 and 99355?

Florida Subscriber

Answer: CPT guidelines tell you to use +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) in conjunction with the following:

• new and established office and outpatient visit codes 99201-99215
• consultation codes 99241-99245
• nursing home, domiciliary, and home visit codes 99304-99350.

You use +99355 (... each additional 30 minutes) with code 99354.

Critical care codes are conspicuously absent from the list of codes you may report with 99354 and 99355, so you should not report prolonged services with critical care.

Example: The patient presents for chemotherapy, and the physician provides a 15-minute 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) service to treat side effects. During the chemotherapy administration, the patient has a severe drug reaction, and the physician spends an additional 50 minutes with the patient caring for this reaction, but the service doesn't meet the requirements for critical care.

You can append one unit of 99354 to report the prolonged service.

Tip: Your insurer may not follow CPT guidelines on restricting codes assigned with prolonged services codes, so check your carrier's rules to be sure.