Ophthalmology and Optometry Coding Alert

Glaucoma Attacks:

One Code Does the Trick

Published on Sun Jun 01, 2003

Dont let the abundance of guidelines for the prolonged services codes deter you from reporting them they may be your only means of receiving additional reimbursement for the extra time your physician spends managing a patients narrow-angle glaucoma attack.

When a patient with glaucoma presents during a narrow-angle (365.22) or angle-closure attack (365.20), pressure in the patients eye can build up rapidly as aqueous fluid blocks the trabecular meshwork. Even though glaucoma attacks are considered emergencies, they are often managed and treated in the ophthalmologists office. Managing these attacks in the office can greatly exceed the amount of time allotted for standard E/M services and to get paid for your ophthalmologists extended services, you may need to use the prolonged services codes.

The prolonged services codes, 99354-99357, represent the face-to-face physician-patient time "that is beyond the usual service in either the inpatient or outpatient service," according to CPT, which is why these services are add-on codes, reported in addition to other E/M codes that include a reference to time, without which, there is no way to determine when a service can be classified as "prolonged."

Sherry Wilkerson, RHIT, CCS, CCS-P, director of coding and compliance for Esse Health in St. Louis, explains how they work. Lets say a physician sees an established patient who is having a narrow-angle attack. The physician provides an E/M service that measured by the key components of history, examination and medical decision-making qualifies as a level-four outpatient visit, 99214, which has a 25-minute physicianto- patient time allotment. But the ophthalmologist spends one hour (35 minutes more than the allotted 25 minutes) monitoring the attack. The ophthalmologist may report 99214 and +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-toface] 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 and other outpatient evaluation and management service]) to account for the additional time he spent monitoring the attack, trying different medications, managing the patients pain, and determining whether the patient will have to have surgery if the topical and oral medications are ineffective.

If the physician had spent less than 55 minutes total time with the patient, or fewer than 30 minutes more than the E/Ms allotted 25 minutes, the ophthalmologist would not have been able to use the prolonged services codes to account for that additional time.

Getting reimbursed for your ophthalmologists time and navigating through the prolonged services guidelines can be a snap if you use the following answers to frequently asked questions about the following codes:

99354

+99355 each additional 30 minutes (list separately in addition to code for prolonged physician service)

+99356 Prolonged physician service in the inpatient setting, requiring direct (face-to-face) patient contact beyond the usual service (e.g., maternal fetal monitoring for high-risk delivery or other physiological monitoring, prolonged care of an acutely ill inpatient); first hour (list separately in addition to code for inpatient E/M service)

+99357 each additional 30 minutes (list separately in addition to code for prolonged physician service).

Q: Are there any CPT evaluation and management codes that the prolonged service codes cant be reported with?

For Medicare carriers and the vast majority of non- Medicare carriers, the prolonged service codes cant be billed with the following:

Hospital observation services

Observation of inpatient care service, including admissions and discharges

Critical care service

Emergency department service, unless the physician is providing an outpatient consultation that goes beyond the typical time spent with a patient.

Another way to look at it is that the outpatient prolonged service codes 99354 and 99355 can only be reported in addition to outpatient visit codes 99201-99205 and 99212-99215, and outpatient consultation codes 99241-99245. And the inpatient prolonged service codes 99356 and 99357 can only be reporting with hospital inpatient codes 99221-99223, subsequent hospital care codes 99231-99233, initial inpatient consultation codes 99251-99255, follow-up inpatient consultation codes 99261-99263, comprehensive nursing facility assessment codes 99301-99303, and subsequent nursing facility care codes 99311-99313.

Q: Can I use the prolonged services codes if the ophthalmologist exceeds the allotted E/M time with a patient by more than 30 minutes, but that time was not all in one sitting?

While it isnt necessary for the time counted toward prolonged services to be continuous, it is important that all of the time intervals spent with the patient be documented, Wilkerson says. The Medicare Carriers Manual section 15511.1 instructs carriers to "Advise physician that to support billing for prolonged services, the medical record must document the duration and content of the E/M code billed." You should also check for documentation that shows that the extra time spent with the patient was necessary. You dont have to go so far as to have documented start and stop times to be reimbursed, but the more detailed the documentation the better.

Q: If the ophthalmologist meets the requirements for reporting a prolonged services code and he meets the requirements for increasing the level of the E/M service because he spent more than 50 percent of his time counseling the patient and coordinating care, do we upcode the E/M level or use the prolonged service codes?

The good news is that either way you decide to code, you should be compensated for the extra time your physician spent with the patient as long as the physicians documentation clearly identifies the time spent with the patient and what was accomplished in that time.

The bad news is that neither CPT nor CMS offers guidance on whether you should report a higher-level E/M service or use the prolonged service codes when, for instance, the physician spends 35 minutes of a 50-minute (face-to-face time) established patient office visit. It would not be improper coding to use either method of coding.

If during a visit, the physician spends more than 50 percent of time and you have documented how that time was spent and have also documented an approximation of the time it took during the visit talking to the patient about counseling for the particular condition, disease or coordination of care, you can use that time element to bump yourself up to the next level of codes simply because you have spent more than 50 percent of the visit, says Victoria Jackson, owner and executive director of OMNI Management Inc., a medical practice management and billing company

"You have to weigh what is in your best interest," when you have the option of using either method of coding: the three key components of history, examination and medical decision-making OR time, Wilkerson says. If you decide to bill a higher-level E/M service based on time, you have to make sure you document the time and a summary of what transpired during the visit. "You cant just say that over 50 percent of the time was spent counseling you have to say exactly how much time and what happened and what was discussed during that counseling." And in either case, you must provide documentation of the time and service in the medical record.

If the ophthalmologist spends fewer than 30 additional minutes face-to-face with the patient, and counseling and coordination of care still exceeded 50 percent of the time allotted to the E/M visit, you cannot use the prolonge service codes and should report a higher E/M level based on time. You also cant use the prolonged services codes, Wilkerson adds, if you are dealing with an E/M visit that starts as a 99215, the highest level of E/M service. You cant code a higher-level E/M service for an established patient than 99215, so you are shortchanging your practice if you dont use the prolonged service codes and the physician has spent more than 30 minutes with the patient on top of the time allotted for 99215, she warns. To bill 99215 and a prolonged service code based on time alone, the physician must have spent one hour and 40 minutes face-to-face with the patient. You cannot add time spent while the patient is dilating, or sitting after receiving an oral medication.

Q: Can the ophthalmologist get paid for more than 30 minutes of additional time spent not face-to-face with the patient but spent discussing the patients condition with other healthcare professionals or arranging treatment in the patients absence?

The short answer to your question is no. Even though CPT does include two codes for prolonged services without direct patient contact +99358 (Prolonged evaluation and management service before and/or after direct [face-to-face] patient care [e.g., review of extensive records and tests, communication with other professionals and/or the patient/family; first hour) and +99359 ( each additional 30 minutes) youll be hard- pressed to find a payer that reimburses for them, Wilkerson says. Most insurance companies just dont want to pay for the nonface- to-face time the physician spends doing things like talking to other doctors, checking records, or talking to the family, she says.

Medicare has not assigned relative value units to these add-on codes, and instructs Medicare carriers not to reimburse for these services. CMS reasoning: "Payment for these services is included in the payment for direct face-to-face services that physicians bill" (i.e., the services are considered "bundled" into any E/M services provided).

Therefore, you cannot bill any Medicare patients for these services, even if the patient has signed an advance beneficiary notice (ABN). You can report these codes for the sake of coding accuracy, just dont expect to see any reimbursement from Medicare.

You may get lucky and find that some third-party payers may recognize and reimburse for non-face-to-face prolonged services codes, but check with the carrier before getting your hopes up.