Part B Insider (Multispecialty) Coding Alert

Learn what codes to use in both an inpatient and outpatient setting

Reporting prolonged services may be complicated, but you could be missing out on extra reimbursement if you don't tackle modifier 21 and prolonged services codes.

Be forewarned: -Payment may be problematic,- says Deanna L. Sherland, CPC, billing supervisor for Southern Illinois Physicians Services in Belleville. Follow these rules, and you-ll know when each is appropriate.

How to Use Modifier 21

Rule 1: When the time your physician spends on an E/M service is less than 30 minutes past the typical time for the highest E/M code in a family (for office or other outpatient services 99205 and 99215; for hospital inpatient services 99223 and 99233), you may use modifier 21 (Prolonged evaluation and management services) on the E/M code.

Example: If the physician provides prolonged E/M services for a new patient 19 minutes past the typical time, you would append modifier 21 only to new patient code 99205 (Office or other outpatient visit for the evaluation and management of a new patient, comprehensive history; a comprehensive examination; and medical decision-making of high complexity). You cannot append modifier 21 to 99201 through 99204 because they are not the highest level.

Examine Time and E/M Level

Rule 2: When your physician provides more than 30 minutes in excess of the supported E/M service level (99201-99215, 99241-99245, 99304-99350, 99221-99233, or 99251-99255), you should use the prolonged care codes (99354-99357). Note: The time does not need to be continuous. -A physician can spend 10 minutes with the patient, go away and come back later,- says Quinten A. Buechner, MS, MDiv, ACS-FP/GI/PEDS, CPC, CCP, CMSCS, president of ProActive Consultants LLC in Cumberland, WI.

Important: Your physician should dictate the appropriate level of E/M service based on the level of history, exam and complexity associated with the care or based on time if he spent the majority of face-to-face time in counseling or coordination of care. Remember: The E/M service level does not need to be the highest possible level to add a prolonged service code to it. 

Example: The cardiologist conducts a comprehensive history and a comprehensive exam during a hospital admission with a moderate level of complexity (99222, Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity).

Due to the nature of the service, the doctor spent 90 minutes rendering it. But he did not spend the majority of this time in counseling or coordination of care. In other words, he dictated the supported service level by history, exam and complexity rather than time. CPT says that a typical 99222 includes 50 minutes of care. The additional 40 minutes provided during this encounter permits you to bill +99356 (Prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service; first hour [list separately in addition to code for inpatient evaluation and management service]) in addition to 99222.

Don't Overlook Direct Services

Rule 3: Count the cumulative time your physician spends providing the patient either direct (face-to-face) or without direct services (+99358, Prolonged evaluation and management service before and/or after direct [face-to-face] patient care [e.g., review of extensive records and tests, communication with other professionals and/or the patient/family]; first hour; and +99359, ... each additional 30 minutes) on that given date.

In other words: Before or after face-to-face services may include:

- review of records
-  test results
-  communication with other healthcare professionals or family, including phone time.

Focus on Site of Service

Rule 4: Choose the direct prolonged-service code based on the site of service. For outpatients, use:

-  +99354--Prolonged  physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service; first hour (list separately in addition to code for office or other outpatient evaluation and management service)

-  +99355--... each additional 30 minutes (list separately in addition to code for prolonged physician service).

Inpatient codes include:

-  +99356--Prolonged physician service in the inpatient setting, requiring direct (face-to-face) patient contact 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 physician service).

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Rule 5: Use the direct-care time minus the time built into the reported E/M service to assign the correct code combination.