Orthopedic Coding Alert

You may think reporting prolonged services is complicated, but you could be missing out on extra reimbursement if you don't tackle modifier 21 and prolonged services codes.

Be forewarned: Payment may be problematic, but if you follow these rules, you-ll know when each is appropriate. "As always, payment may be impacted by your local carriers and managed-care contracts," says Linda Martien, CPC, CPC-H, coding specialist with National Healing Corp. in Boca Raton, Fla. "Check their local coverage determinations or policies first."

"It's been my experience that only Medicare pays for prolonged services codes," says Suzan Hvizdash, CPC, physician educator for UPMC's department of surgery.

From AMA: The September 2000 CPT Assistant says, "If time is considered the key or controlling factor in choosing the level of E/M service, then the prolonged services codes (99354-99357) should only be used in addition if the service has exceeded 30 minutes beyond the highest level of E/M in the appropriate category."

Consequently, "you cannot use prolonged services with a code unless the E/M code has a time value in it," Hvizdash says.

Rule 1: When the time your orthopedist spends on an E/M service is less than 30 minutes past the typical time for the highest E/M code in a family (for office or other outpatient services, 99205 and 99215; for hospital inpatient services, 99223 and 99233), you may use modifier 21 (Prolonged evaluation and management services) on the E/M code. But keep in mind that when you report modifier 21 appended to an E/M code, your physician's face-to-face time with the patient must be continuous rather than intermittent.

"However, according to the September 2000 CPT Assistant, the add-on codes 99354-99357 can be added to any level unless the majority of time is spent in counseling and coordination of care," Hvizdash says. "If the prolonged services are for counseling/coordination of care, then you should go to the highest level in the appropriate E/M category before adding prolonged services codes. If the time is spent doing a procedure for which there is no billing code or for other services such as monitoring a patient, then you add prolonged services onto the appropriate E/M code at any level."

Example: If the orthopedist provides prolonged E/M services for a new patient 20 minutes past the typical time discussing risks, benefits and alternatives to spine surgery, you would append modifier 21 only to new patient code 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of high complexity). You cannot append modifier 21 to 99201 through 99204 because they are not the highest level, Martien says.

Rule 2: Use prolonged services in addition to the E/M service code when care is 30 minutes or more beyond the usual service of a time-based code. Keep in mind that the time does not need to be continuous for 99354-99357. A physician can spend 10 minutes with the patient, go away and come back later to spend additional time on the same day.

"So, if a physician intends to bill for prolonged care, he/she will need to document a note similar to: -I spent 1 hour and 15 minutes in direct face-to-face contact with the patient today to coordinate plans for ...- " Hvizdash says.

Example: Your orthopedic surgeon sees an established patient and spends an extra 45 minutes in addition to a 99214 service. These 45 minutes may be comprised of the initial face-to-face encounter of 15 minutes, then return visits to the patient's bedside two more times for 10 minutes each, and finally, 10 minutes spent reviewing the chart and talking to the patient's family, Martien adds. For this visit, you should report +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service ... first hour [list separately in addition to code for office or other outpatient evaluation and management service]) as well as 99214.

Rule 3: Count the cumulative time you spend providing the patient either direct (face-to-face) or without direct services on that given date for inpatients (+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).

In other words: Services your orthopedist may perform before or after face-to-face services may include:

- review of records

- test results

- communication with other health professionals or family, including phone time.

Rule 4: Choose the direct prolonged service code based on the site of service.

For outpatients use:

- +99354

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

Inpatient codes include:

- +99356 -- Prolonged physician service in the inpatient setting requiring direct (face-to-face) patient contact beyond the usual service; first hour (list separately in addition to code for inpatient evaluation and management service)

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

Rule 5: Use the direct-care time minus the time built into the E/M service reported to assign the correct code combination, Hvizdash says. This is shown in the chart below.