Otolaryngology Coding Alert

Prolonged services are a good way for otolaryngologists to get reimbursed for significant extra time spent caring for patients. Physicians treating pediatric patients and those with cancers of the neck, throat or thyroid, for example, particularly stand to benefit financially by coding and billing for prolonged services when appropriate.

There are, however, two hurdles to overcome before these benefits can be realized:

1. Many practices are unfamiliar with billing these
evaluation and management (E/M) services.

2. Many otolaryngologists dont document their time
adequately, but time is the critical compliance guideline when using and billing for these services and the key to successful reimbursement.

There are two sub-categories of prolonged services in CPT 2000direct, or face-to-face contact, and without direct contact. From a reimbursement standpoint, the face-to-face codes are more important because most carriers wont pay for nondirect prolonged services.

The face-to-face codes are further categorized as inpatient or outpatient. There are four such codes:

99354prolonged 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 in an outpatient setting); first hour (list separately in addition to code for office or other outpatient evaluation and management service)

99355each additional 30 minutes (list separately in addition to code for prolonged physician service) (Note: This code follows 99354.)

99356prolonged physician service in the inpatient
setting, requiring direct (face-to-face) patient contact beyond the usual service (e.g., maternal fetal monitoring for high risk delivery or other physiological monitoring, prolonged care of an acutely ill inpatient); first hour (list separately in addition to code for inpatient evaluation and management service)

99357each additional 30 minutes (list separately in addition to code for prolonged physician service) (Note: This code follows 99356.)

Four Coding Tips

1. Prolonged Services Codes Cant Be Used on Their Own. The first thing to note about prolonged services codes is that they are add-on codes, which means they cannot be billed on their own but must accompany another E/M service, says Barbara Cobuzzi, MBA, CPC, CPC-H, an independent coding and reimbursement specialist in Lakewood, N.J. And because these codes are time based, they can be added only to E/M services that have a time component, or reference time, built in, Cobuzzi says, such as hospital admissions, inpatient follow-up care, consults or office visits.

Note: When more than 50 percent of the physician/patient or physician/family encounter is spent counseling or coordinating care, time supersedes history, exam and decision-making and becomes the key factor for determining the E/M service level.

Billing a prolonged service code as an add-on to an emergency department visit code (99281-99285) is incorrect, however, because these codes are timeless in that they have no time component. Consequently, there is no way to indicate what, in fact, was prolonged. You cant determine that a service is prolonged without a reference time, Cobuzzi says.

The otolaryngologist can, however, bill prolonged services to get paid for time spent in the emergency room (ER) if he or she determines that the patient should be admitted. For example, a patient comes into the ER with severe infection, high fever, sore throat, nausea and vomiting, and the otolaryngologist determines that the patient must be admitted for IV antibiotics. The otolaryngologist performs a full workup in the ER and then does a level two admission (99282).

In this situation, Cobuzzi says, If the total time the otolaryngologist has documented is equal to or exceeds 30 minutes beyond the reference time for the admit, the first hour of prolonged services (99356) may be billed. The otolaryngologist did a level two admit, which has a reference time of 50 minutes. If 80 minutes of time spent with the patient can be documented between the emergency department chart and the admission chart (80-50=30), then both 99222 (initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: comprehensive history, comprehensive examination, and medical decision-making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patients and/or familys needs ... Physicians typically spend 50 minutes at the bedside and on the patients hospital floor or unit) and 99356 could be billed.

Office visits also include reference times for those situations when counseling the patient or coordinating care constitutes more than 50 percent of the visit. For example, during an office visit, an established patient is told about a laryngeal cancer diagnosis (161.9). In this situation, the otolaryngologist may spend 70 minutes with the patient counseling and/or coordinating care. Even with a level five established patient code (99215, office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: comprehensive history, comprehensive examination, medical decision-making of high complexity ... Physicians typically spend 40 minutes face-to-face with the patient and/or family), only the first 40 minutes of the encounter have been coded. The remaining 30 minutes may be billed using prolonged services code 99354.

Note: One hour of prolonged services (99354 and 99356) is considered to be 30-74 minutes of documented time.

2. Document All the Time Spent With the Patient. Prolonged services are one of three E/M code categories that are entirely time based. (Critical care and care plan oversight are the other categories.) That means that the regular E/M categorieshistory, exam and medical decision-makingdo not apply when billing for prolonged services. Instead, the amount of time spent face-to-face with the patient determines which code to bill.

Otolaryngologists should document all the time spent with the patient, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding and reimbursement consultant and educator in North Augusta, S.C. But remember, once youve passed the halfway point of any given segment of time, youll be given credit for the entire segment, she says.

The time, however, must be documented; just stating that the otolaryngologist spent 30 minutes or an hour with a patient does not count. Medicare will pay about $100 for the extra 30 to 74 minutes documented, Cobuzzi says.

To charge for each additional half-hour of prolonged services (99355 for outpatient and 99357 for inpatient), at least 15 minutes of the additional 30 minutes claimed must be documented. With any time-based code, whether critical care or prolonged service, once 30 minutes of the first hour (30-74 minutes HCFA time) is documented, youve met the documentation requirements for the first hour, Cobuzzi says. The same applies for the next 30 minutes, she notes. Once 75 minutes of face-to-face contact is documented, the otolaryngologist can charge for another half hour.

Note: Start and stop times, while not required, should be documented.

3. Apply Non-direct Time to Original E/M Service. The 50-minute reference time for a level two hospital admission (when time is used for counseling or coordination of care beyond 50 percent of the encounter) does not include only face-to-face time, but also includes floor-time on the unit. The documented time to support billing with prolonged services codes 99354-99357, however, must be face-to-face time spent with the patient. For instance, if the otolaryngologist spends a total of 80 minutes with the laryngeal cancer mentioned previously, at least 30 minutes must be direct or face-to-face contact. The otolaryngologist, therefore, should document ordering labs or consults, conferring with other physicians or staff, and evaluating lab results, other chart notes and consults already performed because these are all part of the floor time for any inpatient service and may be counted as part of the admission. Physicians can include all those seemingly extraneous tasks if they document what they did, Cobuzzi says.

If some of the floor time included in the admission code is spent on the floor talking to the family about the patients condition, that too may be included, Cobuzzi says. She notes, however, that encounters with family members should take place in the patients ward; meetings in the chapel or the ER while doing other work do not apply.

She also recommends that physicians note in the patients chart that the admit is a continuation of the time already spent in the ER, even though there is a separate ER chart. That way, she says, if someone reads the inpatient chart only, it can stand on its own.

4. Dont Overuse These Codes. Cobuzzi strongly recommends that practices restrain themselves from using prolonged services codes when they can because overuse definitely will attract unwanted attention.

There is an unofficial guideline that states that prolonged services shouldnt exceed 10 percent of total E/M billed, Cobuzzi says, but I think thats far too liberal. Personally, I wouldnt go much higher than 1 percent.

Note: Prolonged services were added to the E/M section of the CPT book in 1995. Some payers use older versions of the book and therefore do not recognize or pay for such claims. If your prolonged services claim is denied for no apparent reason, you should appeal. If more positive results are not forthcoming, contact your state department of insurance.