Oncology & Hematology Coding Alert

Experts answer your prolonged care FAQs

Don't let the abundance of guidelines for codes 99354-99355 deter you from properly reporting prolonged services - they may be your only means of receiving additional reimbursement for your oncologist's extra time.
 
Experts answer three frequently asked questions to help you master prolonged service coding:

Q. When should we use prolonged service codes?

You should report prolonged care codes 99354-99355 only for your oncologist's face-to-face patient service "that is beyond the usual service in either the inpatient or outpatient setting," according to CPT. You shouldn't use prolonged care codes when nonphysician staff treat a patient. Report prolonged services in addition to other physician services, including all levels of E/M codes, such as 99211-99215, coding experts say.
 
Use prolonged service codes as add-on codes when an E/M visit exceeds the highest level of basic E/M service, such as 99215. Bill 99354-99355 when the total duration of all physician face-to-face service equals or exceeds the E/M service's threshold time by 30 minutes. For example, if the physician's service goes 30 minutes beyond CPT's 15-minute timeline for 99213 (Office or other outpatient visit ... established patient ...), you may be able to use 99354. If the oncologist doesn't meet this standard, however, you can't bill for prolonged services, coding experts say.
 
For example, a patient with breast cancer (174.x) presents to the oncologist for the patient's first chemotherapy administration, which involves a three-hour infusion of paclitaxel (J9265). You would assign 96410 (Chemotherapy administration, intravenous; infusion technique, up to one hour) to the initial chemo administration, and then use +96412 (... infusion technique, one to 8 hours, each additional hour [list separately in addition to code for primary procedure]) for the infusion. In addition, the physician discusses with the patient the chemotherapy treatment and possible side effects.
 
After the oncologist initiates the paclitaxel infusion, the patient exhibits shortness of breath (786.05). The physician then administers emergency medications, which include IV diphenhydramine (J1200) and Solu-Medrol (J2920). The oncologist offers additional evaluation and counseling, instructing the patient that allergic reactions most often occur during the initial chemo dose. The doctor will provide premedications and closely monitor the patient during future treatments, says Margaret M. Hickey, MS, MSN, RN, OCN, CORLN, an independent oncology coding consultant based in New Orleans.
 
Overall, your oncologist spends three hours in face-to-face contact with the patient.
 
You should code the physician's E/M service as 99214 (Office or other outpatient visit ... for an established patient), which allots doctors 25 minutes to perform the service. And you could assign +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]) for the first hour of the oncologist's prolonged service, and use +99355 (... each additional 30 minutes [list separately in addition to code for prolonged physician service]) for each additional 30 minutes. But you cannot bill for fragments such as five or 10 minutes.

Q. Which E/M codes should we not report with 99354 and 99355?

You should not report prolonged service codes with critical care codes. For instance, the oncologist administers chemotherapy (96410) to a patient with non-Hodgkin's lymphoma (202.8x, Other lymphomas). Two weeks later, the patient presents with fever (780.6), respiratory distress (786.09), and low blood pressure (458.x).
 
After examining the patient, the physician admits the patient to the critical care unit for septic shock (785.52), Hickey says.
 
Because the oncologist provided critical care services, not prolonged care, you should report 99291 x 1 (Critical care ...; first 30-74 minutes) for the first 60 minutes of service, and +99292 x 3 (... each additional 30 minutes [list separately in addition to code for primary service]) for the additional 90 minutes of critical care, says Antoinette Revel, CPC, a coding expert and nurse practitioner working at Healthcare Consulting Services in Warrington, Pa.
 
Not all insurers restrict prolonged care usages with the E/M services listed above, so ask your carrier for specific guidelines regarding which codes you can use with these prolonged service codes.

Q. Can we use 99354 or 99355 if our oncologist exceeds the allotted E/M time by more than 30 minutes at different sittings?

Although CPT doesn't require that your physician perform prolonged service on a continuous basis, 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 (MCM).
 
MCM, however, states that physicians don't have to submit documentation along with the claim for prolonged service codes.
 
But you should have the documentation available in case a Medicare carrier targets your physician for medical review.
 
Suppose the oncologist sends a patient for x-rays (70010-76499) and computed tomography (CT) scans (76070, Computed tomography, bone mineral density study, one or more sites; axial skeleton [e.g., hips, pelvis, spine]). The physician and the patient discuss results from interpretation x-ray films (71010-26, Radiologic examination, chest; single view, frontal; professional component) and a treatment plan, which takes another 45 minutes.
 
The visit's time reaches 105 minutes, which is 45 minutes beyond the expected time of 99205. In that case, you could use 99354 or 99355 even though radiologic studies broke up the visit.
 
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, Revel says.