Orthopedic Coding Alert

Watch out: There are different codes for the inpatient and outpatient settings 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. Grasp These Prolonged Care Concepts 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 [...]