Part B Insider (Multispecialty) Coding Alert

E/M Mythbuster:

Scrap These 4 Prolonged Service Coding Myths

Published on Mon May 21, 2018

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Hint: Read and review published guidelines to code correctly.

Sometimes visits last longer than the typical time described in the evaluation and management (E/M) codes, 99201-99215 - and that can mean more Part B pay. Complex conditions, counseling, research, and record reviews all take time, and sometimes you can report those extra minutes if you have specific documentation.

Coding prolonged services isn't quite as simple as just reporting an additional code, so it's no wonder there are plenty of myths surrounding this topic. Read on to see how we bust the four most common myths to help you keep your prolonged E/M coding clear and correct.

Mark the Codes to Know

In primary care, four codes cover most, but not all, prolonged service situations:

+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))
99358 (Prolonged evaluation and management service before and/or after direct patient care; first hour)
+99359 (... each additional 30 minutes (List separately in addition to code for prolonged service)).

Distinction: Codes +99354 and +99355 are add-on codes for a number of face-to-face E/M services, including 99201-99215, while codes 99358 and +99359 do not require face-to-face interaction between provider and patient.

Shatter These Coding Falsehoods

Myth 1: If the prolonged service goes for up to 30 minutes, you can report +99354.

Reality: This is a big no-no. CPT^® instructions clearly state that "prolonged service of less than 30 minutes total duration on a given date is not separately reported because the work involved is included in the total work of the evaluation and management codes."

"Prolonged time of less than 30 minutes (physician codes) or 45 minutes (clinical staff codes) is not separately reportable," emphasizes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Documentation is key: "When reporting prolonged services, time needs to be precise. Documentation should detail important clinical matters, and it should also support coding," says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

Myth 2: Any time your physician performs a prolonged E/M service that is not face-to-face, you can report 99358/+99359.

Reality: Again, CPT^® guidelines for reporting these codes are very strict. To use 99358/+99359, the non-face-to-face service must "relate to a service or patient where (face-to-face) patient care has occurred or will occur, and relate to ongoing patient management," according to CPT^® instruction.

Clarify: The guidelines also state that you cannot report these codes for "time spent in care plan oversight services ... home and outpatient INR monitoring ... medical team conferences ... online medical evaluations ... or other non-face-to-face services that have more specific codes and no upper time limit."

Opportunities: That means you might be able to use the codes if you can document "prolonged communication consulting with other health care professionals related to ongoing management of the patient, or prolonged review of extensive health record and diagnostic tests » regarding the patient," according to CMS guidelines for 99358/+99359. You must also document the additional 30-74 minutes for 99358 and 15-44 minutes for +99359. Unlike reporting +99354-+99355, you don't have to substantiate direct patient contact.

Myth 3: Time spent on E/M services, whether face-to-face or not, has to be continuous in order to qualify for a prolonged service code.

Reality: CPT^® guidelines for all the prolonged services codes state that you should use them to report the total duration of face-to-face or non-face-to-face time spent by a physician or other qualified healthcare professional on a given date "even if the time spent by the physician or other qualified healthcare professional on that date is not continuous."

In fact, you may use 99358/+99359 on a different date if the work involves a service or patient where (face-to-face) patient care has occurred or will occur. CPT^® guidelines explicitly state, "This prolonged service may be reported on a different date than the primary service to which it is related."

Myth 4: Only services provided by a physician or qualified health care professional can qualify for prolonged service codes.

Reality: Actually, there are two different prolonged service E/M codes that describe work of other clinical staff:

+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)).

These codes differ from the physician codes in two very important ways. First, "a physician or qualified health professional" must be present "to provide direct supervision of the clinical staff" for you to report these codes. Second, the minimum time threshold for +99415/+99416 is 45 minutes.

Bottom line: You should reserve prolonged service codes for unusual circumstances that go above and beyond the typical or average time of the documented visit code. To use the codes, "it is important that you record the times for these time-based codes in the medical record," Falbo says.