Orthopedic Coding Alert

See why 30 minutes more than usual is the magic requirement.

If your orthopedist spends more continuous time with a patient than what's specified for 99215 or 99225, you should not look to modifier 21. Why not: CPT 2009 eliminates modifier 21 and instead directs you straight to prolonged service codes.

Modifier 21 (Prolonged evaluation and management services) was an informational code and does not require carriers to give you extra reimbursement. "We don't use modifier 21 anyway," says Joyce A. Shea, senior manager for Patient Financial Services at Impulse Monitoring Inc. in Columbia, Md.

Part of the reason is you could only use modifier 21 with the highest level E/M codes in a grouping, for example, 99205, 99215, 99245, etc. Per CPT 2008, Appendix A, you would use the modifier only with "the highest level of E/M service within a given category" and only on an E/M code. Part of the reason why many practices haven't used modifier 21 is they rarely report these highest level E/M codes.

Reason for confusion: If the time documented did not exceed 30 minutes beyond the CPT allotted time, you could not append modifier 21 to the E/M, experts say.-Because Modifier 21 was redundant in some cases and mysterious to some, eliminating this modifier simplifies your decision.

Benefit of new way: Using a prolonged service code (+99354-+99359), rather than modifier 21, also provides more description.

"The prolonged E/M service codes clarify whether it was face-to-face time with the patient and specify exactly the time parameters involved," explains Jennifer Swindle, RHIT, CCS-P, CPC-EM-FP, CCP, director of coding compliance/charge entry for QLIMG, and director of the coding and compliance division of PivotHealth LLC in Garden City, N.Y.

Providers should code the level of care based on medical necessity and time. Report prolonged E/M services 30 minutes beyond the usual service for direct and indirect patient care using prolonged services codes +99354-+99359.

Example: The orthopedist sees a former patient who was in an automobile accident. At the time of the accident, the patient didn't seek medical attention but has begun to have intermittent back and neck pain. The physician does a full history and examination and documents medical decision making. The E/M medical necessity level meets the criteria for 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history, a detailed examination, and medical decision making of moderate complexity - Usually, the presenting problem[s] are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family). While the actual level of service may have been only a level-four service, the physician spends additional time answering the patient's many questions and helping her to understand her options. The total visit takes 60 minutes.

This visit would be eligible for an additional prolonged service code of +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]) with 99214.

2008 method: In the office setting, you could have used modifier 21 on only 99215 (- a comprehensive history, a comprehensive examination, and medical decision making of high complexity - usually, the presenting problem[s] are of moderate to high severity; physicians typically spend 40 minutes face-to-face with the patient and/or family), but the visit's medical necessity might not have warranted reporting this level of care.

If you were one of the lucky few getting paid for 99215-21, CPT 2009 will disappoint you. "Prolonged service of less than 30 minutes total duration on a given date is not separately reported because the work involved is included in the total work of the evaluation and management codes," according to new CPT notes for +99354 and +99356. Because the reporting guidelines and use of the prolonged service codes (+99354-+99359) made modifier 21 obsolete, the AMA deleted it.

Loss of payment on soon-to-be-included prolonged services, however, will probably not be widespread. Payers in some areas do not recognize modifier 21, experts say.

Prediction: Expect an easier time getting paid for prolonged services that a physician provides face-to-face to a patient. Most payers recognize prolonged services codes for direct patient care, but not for indirect care.