Pediatric Coding Alert

When a pediatrician spends an extended amount of time with a patient, he or she may bill for the extra work by using the prolonged services codes (99354, 99355). 99354 can be used beginning at 30 minutes and covers the time spent with the patient through 75 minutes. If the visit is longer than 75 minutes you would bill 99354 and 99355 (99355 is for each additional 30 minutes, but can be used for the final 15 minutes of prolonged services that have extended beyond one hour).

In some cases, the pediatrician will spend a prolonged amount of time on a patients care, but not all of that time in direct, face-to-face contact, notes Sharon Diaz, office manager of Pediatrics of South Austin (TX), a three-pediatrician group. This illustrates a key issue complicating the use of the prolonged services codes.

Take the example of a patient who is having an asthma attack and needs nebulizer treatment, she explains. The pediatrician spends more than 30 minutes altogether on the patient, but not all face-to-face.

He examines the child, then goes to the lab and orders the nebulizer and other labs. The neb treatment is done for about 15 minutes. Then the doctor listens again. It only takes a couple of minutes to determine whether treatment is needed again, Diaz explains. Therefore, does the 30 minutes include the procedure or just the exam?

For an asnwer we consulted Tina Cressman, pediatric billing specialist for Cooper Pediatrics, a 45-pediatrician multi-specialty group in Cherry Hill, NJ. According to Cressman, the pediatrician can only bill for the prolonged time he or she spends directly in contact with the patient. And, that time must be scrupulously documented.

The prolonged services codes can be lucrative for a pediatric practice because they can be used in addition to office-visit codes, but knowing what qualifies as prolonged is tricky. Its important to note that the first 30 minutes of an office visit do not count. (After 30 minutes, you can bill 99354 for the first hour, according to CPT.) And, its also important to note that all of the reported time does have to be face-to-face if the physician is going to use these codes. However, the care does not have to be delivered continuously.

Note: The CPT 99358 -99359 (prolonged physician service without direct, face-to-face patient contact) can be used when a physician provides prolonged service not involving direct care, according to CPT, but, this would not cover a service in which the physician saw the patient part of the time.

Billing Prolonged Services

Here are some tips for correctly using these codes.

1. Track the time in, time out. The pediatrician should document when he goes into the examining room and [...]