Otolaryngology Coding Alert

Know what to do when your provider goes above and beyond routine duties.

Sometimes, you’ll have to turn to a prolonged service code when patient care extends beyond the routine amount of time allotted in outpatient services spanning outpatient code ranges 99201-99215, 99218-99220, 99234-99236 and inpatient services 99221-99233. While the circumstances calling for the use of a face-to-face prolonged service code may vary, the coding fundamentals do not.

Whether it’s a complex surgery, extended counseling, or records review, you need to know when, where, and how to report a prolonged service code when the patient encounter calls for it.

Read on for three expert tips to make sure you’re using the codes correctly to garner all the pay your physician deserves.

Tip 1: Mark the Codes to Know for Direct Patient Contact

When your surgeon (or other qualified health professional) performs prolonged services involving direct patient contact “that is provided beyond the usual service in either the inpatient or outpatient setting,” you can choose from the following E/M codes to report the additional services, according to the CPT® guidelines:

• +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))
• +99356 (Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient Evaluation and Management service))
• +99357 (… each additional 30 minutes (List separately in addition to code for prolonged service)).

Don’t miss: A key distinction between the preceding codes relates to where the physician provides the prolonged services, according to Cynthia A. Swanson, RN, CPC, CEMC, CHC, CPMA, of ClaimDOC in Des Moines, Iowa.

For extended office or other outpatient visits, turn to +99354 and +99355. For a visit with a patient admitted to a hospital, observation status, or other facility, turn to +99356 and +99357.

Tip 2: Make Sure to Document Time

The prolonged service codes +99354-+99357 are defined by time, Swanson says. “As such, practitioners should routinely record the total duration of time they spend face-to-face with the patient in the office or other outpatient setting,” Swanson adds. “In the hospital or nursing facility setting, the practitioner should document the floor or unit time spent to coincide with the reported/billed CPT® prolonged service codes.”

Caution: You cannot separately report a prolonged service that is less than 30 minutes’ total duration on a given day because “the work involved is included in the total work of the evaluation and management codes,” according to the guidelines.

Key: Turn to +99354 or +99356 to report the first hour of prolonged service on a given date, depending on the place of service (POS). You should report either code only once per date, even if the time the physician spends is not continuous on that date, per the guidelines.

More: Look to +99355 or +99357 to report each additional 30 minutes beyond the first hour, dependent upon the POS. You may report either code for the final 15-30 minutes of prolonged service on a given date. However, you cannot separately report a prolonged service of less than 15 minutes beyond the first hour, or less than 15 minutes beyond the final 30 minutes.

Don’t miss: “There is a common misunderstanding that prolonged services with patient contact can only be billed after the time for the highest E/M code of the code set (e.g., 99205, 99215, or 99223) has been exceeded,” explains Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington. “This is only true if the entire encounter is based on time (i.e., based on counseling and/or coordination of care). If the base E/M code is based on the elements (history, exam, decision making) then prolonged services can be added to any E/M code once the typical time for that code has been exceeded.”

Tip 3: Follow Rules for Add-On Codes

The + symbol before each of these codes means that they are “add-on” codes, which cannot stand alone, explains Linda Martien, CPC, COC, CPMA, AAPC Fellow. Always use an add-on code in addition to an appropriate base code.

For instance, 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; medical decision making of moderate complexity …) would be your base code and +99354 would be the add-on code if the provider spent 30 minutes to one hour in prolonged service, according to Martien.  Since the reference time for 99214 is 25 minutes, a total time of 55-85 minutes must be documented to bill 99214 plus +99354 since 30-60 minutes must be spent with the patient in addition to the reference time associated with 99214. 

Coding tip: Always report the add-on prolonged services in addition to the primary procedure, such as the designated E/M service on any level, psychotherapy code 90837 (Psychotherapy, 60 minutes with patient), family psychotherapy code 90847 (Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes), and any other services the physician provides at the same session, according to the guidelines.