Otolaryngology Coding Alert

See how time plays a key role in the coding process.

When you get down to the gritty details of evaluation and management (E/M) coding, there’s seemingly always room in one facet of the discussion or another to clear up some lingering sources of confusion. Today, you’ll cover one subject area within E/M that’s overdue for a little further explanation on how to code correctly: prolonged services.

Specifically, by answering two of the most frequently asked questions pertaining to prolonged E/M visits, you’ll gain a much firmer understanding of when, and when not, to utilize these types of services.

Have a look at two of the most pressing questions coders are asking about prolonged E/M services.

Code First to Highest Established E/M Level

FAQ 1: Can I bill +99354 with 99214?

First, if you are considering the use of prolonged E/M 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 or psychotherapy service)), you need to know that you may submit code 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; ...) so long as you reach 99214 visit qualifications using the 1995/1997 E/M guidelines. However, if you’re reporting based on a time estimation, you may only do so when you’ve reached 99215. That’s because, as the Centers for Medicare & Medicaid Services (CMS) explains in MLN Matters #MM5972, “in E&M services in which the code level is selected based on time, you may only report prolonged services with the highest code level in that family of codes as the companion code.”

“This means that if the time of the established patient visit only allows you to reach 99214, then you may not report a prolonged services code in addition to the E/M code,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, AAPC Fellow, of CRN Healthcare in Tinton Falls, New Jersey. “However, if you use history, exam, and medical decision making [MDM] to determine the E/M visit, you may report any code within code range 99212-99215,” Cobuzzi explains.

So, if you are thinking of reporting of a prolonged services E/M code in addition to your time-based established patient visit, you first need to make sure you’ve got the documentation to reach code 99215 (…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 comprehensive hist ...).

Refresher: “Since E/M codes can have time considerations when providing counseling and coordination of care, you first need to exhaust the time supported in your E/M visit,” says Marie Popkin, BS, CPC, project manager at Aviacode in Salt Lake City, Utah. “Providers may feel they deserve to be paid for their time without understanding how to document for time or how to properly support these services as per the coding guidelines.”

In order to reach 99215 using time-based rules for E/M reporting, the physician would have to document greater than 50 percent of the visit performing counseling/coordination of care services. This means that the physician must document more than 20 minutes providing counseling/coordination of care services for an E/M visit that exceeds 40 total minutes. This is based on the “typical” 40-minute time estimation for 99215 outlined in the CPT^® manual. This time estimation is important in determining the prolonged services code. While you may reach 99215 using the three key components, you cannot begin to document the time for a prolonged services code before provider reaches the 40-minute threshold.

Take Appropriate Steps to Reach +99354

Once you’ve achieved documentation to reach 99215, you then need to confirm that the patient encounter meets the time-based criteria for +99354. First, you should be aware that if the total duration of prolonged services is less than 30 minutes, you should not consider +99354. At the 40-minute mark of the E/M visit, the physician must spend at least 30 more minutes with the patient in order to report +99354 in addition to 99215. If the total length of the visit is less than 70 minutes, the visit is not eligible for prolonged services coding. For a visit lasting 30-74 minutes beyond the 40 minutes, you’ll report +99354. For a visit lasting 75-104 minutes beyond the initial 40 minutes, you’ll report +99354 and +99355 (… each additional 30 minutes (List separately in addition to code for prolonged service)). If the visit exceeds 105 minutes or more following the initial 40 minutes, you will report +99354, +99355 x 2 units.

Think Twice About Using +99354 Alongside Surgical Procedures

FAQ 2: Can I bill +99354 with an office surgical visit?

While +99354 is an add-on code, it’s not meant to be used as an add-on code for a surgical procedure. If the physician performs an in-office surgical procedure and spends an exceptional amount of time performing a related E/M service before or after the procedure, you should not consider +99354 eligible for reporting. However, that doesn’t mean that you cannot definitively report a separate E/M code with modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service). Have a look at the following excerpt in Chapter 1 (General Coding Policies) in the National Correct Coding Initiative Policy Manual:

“The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and shall not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses.”

In any instance where the patient has an E/M service of subject matter unrelated to the minor procedure, you may submit an E/M code with modifier 25. If, on the other hand, the provider spends time prior to the office procedure deliberating on whether the procedure is medically necessary or a useful therapeutic option for the patient, you should not report a separate E/M code in addition to the procedure.

However, NCCI outlines that a scenario exists where you can bill for a minor office procedure alongside an E/M visit using the same diagnosis code. While there’s some room for interpretation, you can consider a scenario where the surgeon performs the office procedure and then spends an atypical amount of time answering the patient’s questions surrounding recovery and prognosis following the procedure.