Oncology & Hematology Coding Alert

Question: Can you report prolonged services with any level of E/M code or just the highest-level E/M codes?

Washington Subscriber

Answer: It's a common myth that prolonged care services can only be reported with the highest level of E/M code, like 99205 (Office or other outpatient visit for the evaluation and management of a new patient...) or 99215 (...an established patient...) for office services. However, this is not true.

You can report prolonged care codes +99354 (Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service)) and +99355 (...each additional 30 minutes (List separately in addition to code for prolonged service)) with any level of E/M code. However, the documentation must support the reason why and give the details of the service.

To report a prolonged care services code like +99354, your clinician should have performed at least 30 minutes of prolonged care beyond the typical time stipulated in the descriptor for that particular E/M code.

For example, a provider typically spends 30 minutes with a patient when performing a 99203 (Office or other outpatient visit for the evaluation and management of a new patient...). When the session extends beyond this time, you can claim reimbursement for the additional time by reporting +99354 and +99355, as appropriate, according to the time spent and documented. Code +99354, the first hour of prolonged care, requires a minimum of 30 additional documented minutes and; +99355 (... each additional 30 minutes after the first hour) requires a minimum of 75 additional documented minutes. Be sure to include the time spent on the visit as documentation must support the threshold time for the basic E/M service before considering the additional time documented for the prolonged service codes. Anything less than 30 minutes of prolonged care cannot be reported as the work involved is included in the total work of the E/M service. The details of the note should also include why the extra time was necessary.

This is different than counseling and coordinating care too. When that occurs, the note should indicate the counseling or coordination of care along with the total time of the visit and the indication that more than half of that time was spent in that activity. When the code for an evaluation and management service is selected based on time, the prolonged services may only be reported with the highest level in the family of codes selected as the companion code for the prolonged service. For example, if documentation for an established patient office visit states, "75 minutes spent with the patient, greater than 50% in counseling" and a description of the counseling is present, you must maximize the time for the visit code prior to considering the additional time. In this case 99215 would be selected for the first 40 minutes and the remaining 35 minutes would support one unit of +99354 as the halfway point of the first hour of prolonged service has been met.

The prolonged codes are used when the actual E/M service is extended.