Oncology & Hematology Coding Alert

Question: What are the documentation criteria for using prolonged services codes? My oncologist wants to report both 99213 and 99354. The documentation supports reporting 99213, but what needs to be documented to use 99354? I can tell he spent an hour with the patient by looking at when the next patient was seen, but I'm sure that's not enough.


Washington Subscriber

Answer: The encounter must meet several criteria for you to use the outpatient prolonged service codes +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]) and +99355 (... each additional 30 minutes [list separately in addition to code for prolonged physician service]).

First, you can count only the time spent face-to-face with the patient by the physician in selecting the appropriate prolonged service code.

Second, the physician must provide at least 30 minutes of direct service beyond the usual time for the E/M service.

Third, you must make sure the medical record clearly documents the content and duration of the E/M visit and the prolonged services that the internist provided.

To bill 99213 (Office or other outpatient visit ...) along with 99354, your physician must have spent more than 45 minutes face-to-face with the patient. This encounter would not qualify as a prolonged service if the patient was in the office receiving treatment for more than 45 minutes but the physician's total face-to-face time with the patient was less than 45 minutes.

The Medicare Carriers Manual provides detailed information on prolonged service codes, along with a chart noting the threshold times for using prolonged service codes with E/M codes, in Section 15511.