Otolaryngology Coding Alert

Here’s your guide to E/M documentation success.

Wintertime can be difficult for patients with asthma, as the cold can exacerbate their symptoms. The next time your physician provides education for an asthma patient, double check how you calculate the elements of the visit, because you could garner extra payment for prolonged care.

Start With Counting the Minutes

Consider this scenario from a Codify member. “A new patient visited our office with breathing problems. The physician took a comprehensive history and conducted a thorough examination. After diagnosing asthma, the physician used the session for asthma education; she spent two hours and 20 minutes supplying education and materials for the patient and answering questions. How should we code this visit?”

Check the times: If the physician has documented that she spent more than 50 percent of the total face-to-face time with the patient on counseling and coordinating care, the case is eligible to bill based on time. When you code based on counseling, remember that the documentation must reflect the total time that the physician spent with the patient and the total time spent counseling (ignoring the level of History, Exam, and Medical Decision Making). Your provider also needs to outline the topics covered during the counseling.

Sometimes – as in this case – even the highest level E/M service does not sufficiently account for the two-hour visit in which the physician provided extended counseling to the patient. If enough extended time was spent face-to-face with the patient, it is possible that prolonged services could also be coded and billed in addition to the new patient visit based on counseling time.

In the scenario above, you can report E/M code 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity…) to account for the first 60 minutes of the encounter. Also include prolonged services code +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 service]) to account for the next 60 minutes of the encounter. Finally, add +99355 (… each additional 30 minutes [List separately in addition to code for prolonged service]) for the last 20 minutes spent.

Here’s why: CPT^® calls for the use of code 99354 for prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (e.g., prolonged care and treatment of an acute asthmatic patient an outpatient setting).  Code 99354 can be used once the physician has spent 30 minutes beyond the reference time for the base E/M code to which you are adding 99354.

“And you continue using 99354 through the mid-point of the hour that this first hour of prolonged services until 74 minutes (just shy of the mid-point of the next half hour that is part of the description of 99355,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, vice president at Stark Coding & Consulting, LLC, in Shrewsbury, N.J. “You can then use 99355 once 75 minutes have been documented as expended face to face through 104 minutes. Each time based code is considered satisfied when half the time represented by the code has been met and documented.”

Result: Since the total time spent face-to-face with the patient was 140 minutes (of which 80 minutes were in excess of the reference time of 99205’s 60 minutes), you code it as 99205, +99354, and +99355. The documentation must reflect that in all that time, your physician spent at least 110 minutes counseling if the base E/M code (99205) is based on counseling. Otherwise, the base E/M would have to be based on the level of history, exam, and medical decision making performed within the context of the medical necessity of the nature of the presenting problem.

Code separately for any supplies your physician provided during the visit. However, any time expended for any other procedures (for example, performing a PFT) cannot be counted in the above times.

Good to know: Prolonged services do not have to be added only to the highest code in an E/M family.  Therefore, if the documentation supported only a 99203, for example, but the extra counseling lasted an additional 45 minutes beyond the reference time for 99203 of 30 minutes (total 75 minute encounter), you can report 99203 and +99354.

Plus: Support the E/M visit with the appropriate diagnosis code for asthma from ICD-10 family J45.-- (Asthma) along with R06.02 (Shortness of breath).

Be Prepared to Appeal

Payers may sometimes ask for detailed notes to help justify your use of 99354 – or they might outright deny the claim. You can appeal with the payer by providing a copy of the progress note, which should supply the details of the counseling, as well as a copy of any patient materials reviewed and provided to the patient.

Tip: Check your local payers’ policies thoroughly before billing cases with 99354. That way you’ll know what each payer expects and hopefully can include all the information with your original filing.

“Many non-Medicare payers do not recognize prolonged services and you often will find that you cannot get these add on codes paid for even when they are supported by the documentation and medical necessity,” Cobuzzi says. “Don’t stop using these codes when this is the case. Still submit the services because they are validly being provided and then when they are not paid, write them off as ‘prolonged services not paid’ when the claims are not paid. This way, you can quantify how much this policy of not recognizing valid CPT^® (HIPAA code set). Once quantified, you can go to contract negotiations, showing the payer how much you are losing by the particular payer not covering prolonged services and try to negotiate those losses into increasing your fee schedule for all E&M services, spreading your losses over all services for the coming contract term.”

NPP notes: If a physician assistant or nurse practitioner (non-physician practitioner, or NPP) provides counseling and education services to a non-Medicare patient (instead of the physician doing so), and if the NPP does not have a separate NPI number with the non-Medicare payers, and you will bill the NPP counseling and education services “incident-to” the physician and the claims will go out under the physician’s name and NPI.

Billing under the physician’s name has two critical implications:

• The NPP must practice under direct supervision (physician in the office suite) of a physician; and
• The NPP state license allows for the service within the scope of their state license.

Important: Also, counseling and education must be part of the physician’s plan of care for the patient. The NPP needs to be an employee (W-2) or contractor (1099) to the practice. These are the Medicare rules for incident-to billing under the physician’s name and NPI. Since the subscriber in the example scenario is billing a non-Medicare payer, the coder should confirm that the payer has the same rules as Medicare. If not, verify the payer’s rules in writing.

The physician’s contract with the insurer must specify that the service, although performed by a physician extender supervised by the doctor, is being billed under the physician’s name because there is no other mechanism to bill for the service in the NPP’s name.