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Part B Insider (Multispecialty) Coding Alert

Part B Coding Coach:

Recoup $105 Extra Per Visit For Extended E/M Services

Published on Mon Mar 22, 2004

Your physician's time isn't free -- use prolonged service codes to bill for extra services.

Big Mistake: Coders sometimes choose not to bill prolonged services because they believe carriers won't reimburse those codes. Even though not all carriers will pay, you still may be missing out on at least $105 per visit if you're not reporting prolonged services.

Physicians may report extended times of service for inpatient and office visits because of time spent counseling and coordinating complicated treatments. You can bill for extended services using prolonged service codes (99354-99359) if the total reported time exceeds the typical time of the appropriate E/M code by at least 30 minutes. Prolonged service codes are used to report the total amount of time the physician spent with a patient on a given date of service, even if the time spent on that day is not continuous.

3 Guidelines Show You How

You have several choices when reporting prolonged services. There are separate prolonged service codes for direct face-to-face outpatient services (99354, 99355), direct face-to-face inpatient services (99356, 99357), and for prolonged physician services without direct patient contact (99358-99359). Use these codes correctly by paying attention to the following key requirements:

1. First you must select an appropriate E/M code based on all components of the visit (history, exam, and medical decision making). Use prolonged service codes when the reported time for services provided is "over and above the particular code" you're billing, explains Anita Carr, CPC, business office manager and assistant practice manager of Endocrine and Diabetes Associates in Louisville, Ky.

For example: A diabetic patient presents for a routine check-up and the physician provides all the documentation for a level 3, established patient office visit, including 15 minutes face-to-face time. However, when the patient's routine lab tests reveal a low blood sugar, the physician decides the patient should stay in the office, drink some juice, and have his blood sugar checked again. 

The physician then documents an additional 35 minutes spent discussing the new lab results, the patient's management of his blood sugar levels, and several lifestyle factors that affect the patient's ability to effectively manage his diabetes. You CPT 99213 (Office or other outpatient visit for the evaluation and management of an established patient) for the basic E/M service and 99354 (Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service; first hour) for the extended service time. You'll get paid approximately $105 for 99354.

2. Clock each visit and calculate the total time of physician services. To paint a clear picture of the total extended services, all parties involved in patient service -- physicians, nurses, and even lab technicians, if applicable -- should document the start and stop time of the care they provide, explains Carr.

The physician should track the start and stop time of the entire visit and each time he or she enters and leaves the exam room. You can then add up all the times to determine the total prolonged time for that day. Remember, to bill for prolonged services the physician has to be involved in direct patient care and present in the office, but the provided service does not have to be continuous face-to-face patient contact, she adds.

Check out this example: A patient recently diagnosed with breast cancer (174.4 - Malignant neoplasm of female breast, upper-outer quadrant) presents for an initial visit with an oncologist. The oncologist provides all the documentation to report 99244 (Office consultation for a new or established patient). However, during the visit the oncologist is in and out of the room several times to confer with other physicians, review test results, and arrange the appropriate plan of care. She also reports considerable time explaining the condition to the patient, counseling, and pacifying the patient's many concerns about treatment. The oncologist documents each time she enters the exam room and each time she leaves. From this documentation you calculate the physician's total time in attendance to be one hour and 50 minutes. You therefore report 99244 (which includes 60 minutes) and then 99354 for the 50 minutes of prolonged outpatient service.

Careful: The time requirements involved in both the E/M codes and prolonged service codes can confuse coders. Remember, you must have at least 30 minutes of reported services in addition to the time requirement for the E/M, advises Carr. If the extra time for the visit is less than 30 minutes, you can't bill for the extra time because it's built into the E/M code. So, if you bill a 99203 (Office or other outpatient visit for the evaluation and management of a new patient), which requires 30 minutes, you can bill 99354 only if you have an additional 30 minutes of reported services. In other words, you would need at least one hour of timed services.

Wrapping it up: You can bill the final 15-30 minutes of prolonged service on a given date by reporting an additional 99355 or 99357. "Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately," according to CPT.

3. Bill prolonged service codes with the appropriate E/M codes. For example, you must bill 99354 (Prolonged service in the outpatient setting, requiring direct patient contact) and 99355 (...each additional 30 minutes) with one of the following:

  • 99201-99215 (office or other outpatient services)
  • 99241-99245 (office or other outpatient consultation)
  • 99301-99303 (comprehensive nursing facility assessment)

    Similarly, you must bill 99356 (Prolonged service in the inpatient setting, requiring direct patient contact) and 99357 (...each additional 30 minutes) with one of the following:

  • 99221-99233 (hospital inpatient services)
  • 99251-99255 (initial inpatient consultation)
  • 99261-99263 (follow-up inpatient consultation)

    Beware These Prolonged Service Coding Pitfalls

    Coders may find it hard to differentiate between prolonged services codes, counseling codes, and coding by time, Carr says. The main thing to remember is that you should use counseling codes 99401-99404 when the only service provided is counseling -- no physical exam, history, or medical decision making. CPT also says you can select an E/M code based on time when 50 percent or more of a visit is spent in counseling and/or coordination of care. The important thing when coding by time is that the physician must be in constant, uninterrupted face-to-face contact with the patient. For example, some practices choose to code by time for their diabetes self management training.

    Prolonged service codes are the best choice when billing for services that are not continuous and for extended service times that exceed the typical time limit for a level five code.
     
    Payment Will Vary for Prolonged Services

    Medicare will only reimburse you for prolonged service codes with direct (face-to-face) patient contact (99354-99357). Since Medicare has not established RVUs for codes 99358 and 99359 (Prolonged evaluation and management service before and/or after direct (face-to-face) patient care), many third party payers also refuse to pay for these services. You can use codes 99358 and 99359 to report a physician's time researching or contacting other physicians for information, but in general these codes are seldom useful, Carr explains.

    Medicare and third party payers show a mixed response to the direct prolonged service codes (99354-99357), explains Judy Richardson, senior consultant with Hill & Associates in Wilmington, N.C. Many carriers will request documentation before deciding to pay, and some third party payers do not accept prolonged service codes in addition to high-level E/M service codes, she says. Contact your local Medicare carrier and other payers to see exactly when and how they will pay for prolonged services.

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