Oncology & Hematology Coding Alert

Confused about the exception to prolonged services rules that you to apply to an exception to E/M rules? The AMA offers up an explanation to simplify your coding.

E/M rule: When the doctor spends more than half of E/M service time on counseling or coordination of care, you may use time to qualify for a given E/M level.

Example: If the doctor completes a level-three established patient office visit (such as expanded problem-focused history and exam), but he spends 25 minutes (the average time for a level four) with the patient and more than half of that time involves counseling or coordination of care, you may code a level four (99214).

Prolonged services rule: When the above time rule controls your E/M choice, the doctor needs to spend 30 minutes more than the category's highest level code's average time (as stated in the descriptor) before you report a prolonged service code, according to CPT Assistant (November 2005).

Example: The doctor completes an expanded problem-focused history and exam on an established patient (meeting level three requirements). It takes 70 minutes, and more than half the time involves coordination of care. Time dominates your E/M code choice, so you should report 99215 (Office or other outpatient visit for the-evaluation and management of an established-patient - Physicians typically spend 40 minutes face-to-face with the patient and/or family), and report the additional 30 minutes with 99354.

Don't miss: When time controls your E/M choice and the service doesn't last 30 minutes beyond the highest E/M, you should append modifier 21 (Prolonged evaluation and management services) to the E/M code, CPT Assistant says.