Otolaryngology Coding Alert

CPT^® has different codes for different ‘clinical staff.’

If your otolaryngology practice performs a prolonged, in-office evaluation and management (E/M) service with direct patient contact, coding isn’t as obvious as you might imagine.

Why? In-office prolonged services codes with direct patient contact are broken down by certain types of providers. If a physician provides prolonged E/M service, coding will differ than if another staff member performs the same service. Also, not all payers will accept all types of prolonged services codes.

Read on to get the lowdown on which prolonged services code each time a patient receives in-office prolonged E/M service from a provider at your practice.

Choose +99354, +99355 for Physician, NP Prolonged Service

When the physician, or another billing provider such as a nurse practitioner (NP), provides a prolonged E/M service with direct patient contact, you’ll report it with one of the following codes, confirms Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, N.M.:

• +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)  
• +99355, … each additional 30 minutes (List separately in addition to code for prolonged service)

Remember: You must report +99354/+99355 with an E/M service that has a time component, and the otolaryngologist must exceed the typical time of that E/M service by 30 minutes, Witt reminds.

Example: The otolaryngologist performs an office E/M for a new patient. Encounter notes indicate that the otolaryngologist performed an expanded problem focused history and expanded problem focused examination, along with straightforward medical decision making (MDM), during the encounter. However, due to patient concerns, the visit takes 52 minutes, all of which the physician spends with the patient.

For this encounter, you should be able to report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making) with 99354 to show that the service took at least 30 minutes more than the average 99202 visit. According to the 99202 descriptor, “Typically, 20 minutes are spent face-to-face with the patient and/or family.”

As long as you have documentation indicating the total time for the encounter and explaining why the visit took so much longer than the E/M level might indicate — and that the physician provided the entire E/M service — then you could have a prolonged services claim on your hands.

Choose +99415/+99416 for ‘Clinical Staff’ Services

There is also another pair of codes for in-office prolonged E/M services with direct patient contact. When a staff » » member other than a billing provider — such as a physician or NP — performs the prolonged service, choose from the following codes:

• +99415, Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour (List separately in addition to code for outpatient Evaluation and Management service)
• +99416, … each additional 30 minutes (List separately in addition to code for prolonged service).

There are some differences between +99415/+99416 services and +99354/+99355 services. If the provider of the prolonged service is “clinical staff,” you’ll opt for +99415/+99416. Like the +99354/+99355 codes, you must report these prolonged services codes along with an E/M service that has a time component.

You must be sure, however, that the billing provider performed and coded for the initial E/M service and the “clinical staff” provided the prolonged services. Also, you must exceed the typical E/M time by at least 45 minutes in order to consider coding +99415/+99416, Witt explains.

Check with Payer On ‘Clinical Staff’ Definition

According to Witt, a clinical staff member “works under the supervision of a physician or other qualified health care professional, and is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service.”

In other words: A medical assistance (MA) provider, registered nurse (RN), or licensed practical nurse (LPN) would be clinical staff; but a physician assistant (PA) or NP would not be clinical staff, Witt relays.

The rules as to who is “clinical staff” could vary by payer, however. If you have any doubt as to your payer’s specific definition of clinical staff, be sure to consult your contract before considering +99415/+99416.

Important: Clinical staff may not perform, or code for, the initial E/M, Witt confirms. “As clinical staff, they do not have billing privileges and their work in normally part of ‘overhead’ for the practice — except when it applies to +99415/+99416.”

Also, since clinical staff doesn’t have billing privileges, you might not get paid for +99415/+99416, says Suzan Hauptman, CPC, CEMC, CEDC, senior principal of ACE Med group in Pittsburgh, Pa. “Individual payers will decide on whether to cover these [codes] or not,” she says.

Takeaway: If clinical staff provides prolonged E/M service with direct patient contact, it can’t hurt to report the +99415/+99416 codes. Just don’t expect perfect payment results, as payers’ policies are still evolving around these codes.