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Part B Insider (Multispecialty) Coding Alert

Reader Questions:

Does One-Hour E/M Warrant Add-on Prolonged Service Code?

Published on Tue Mar 08, 2011

Question: Our physician provided a one hour E/M service, most of which was spent on counseling, so we reported 99215 and one unit of +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour). An outside auditor came to our practice and said we should not have reported 99354, and told us to write our payer and give back the reimbursement we received for this extra charge. Is this accurate?

Answer: Your auditor is correct. You can only add +99354 if your physician spent an additional 30 to 74 minutes beyond the typical time of 40 minutes allotted for 99215. In your case, the physician spent a total of 60 minutes on the service, but you'd need to spend at least 70 minutes to report 99215 with 99354.

Example: Your physician spends an hour and 15 minutes face-to-face visiting with a 79-year-old patient who has several comorbid conditions, as well as the patient's son. The doctor goes over the problems and counsels the family on potential diagnoses and solutions. "Counseling" is an important word to use related to time-based coding. It is included as an appropriate service to support coding based on time.

Coding advice: In this example, you'll report one unit of 99215 to cover the first 40 minutes, plus one unit of 99354 for the extra 35 minutes of face-to-face prolonged services.

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