Pediatric Coding Alert

To avoid landing your prolonged services coding claims on the denial stack, you've got to apply these new guidelines starting Jan. 1.

If you were one of the lucky few getting paid for 99215-21 (Office or other outpatient visit for the evaluation and management of an established patient ... Prolonged evaluation and management services), CPT 2009 will disappoint you.

2008 way: "If the time documented did not exceed 30 minutes above the CPT allotted time," you could append modifier 21 to the highest level E/M code in a category, says Lynn A. Brown, CPC, director of physician coding and reimbursement

at CHS in Birmingham, Ala.

New method: Because the reporting and use of the prolonged service guidelines make modifier 21 obsolete, the AMA deleted modifier 21. "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," according to new CPT notes for 99354 and 99356. Loss of payment from the less than 30-minute time however, will probably not be widespread.

Payers in some areas do not recognize modifier 21, Brown notes.

CPT 2009 eliminates incorrectly adding modifier 21 onto a 99214 or 99222 (Initial hospital care, per day, for the evaluation and management of a patient ...) that took longer than usual by directing you instead to the prolonged services codes.

"Providers and billers would forget that modifier 21 was allowed only for the highest level E/M code in a category," Brown recalls.

Using a +99354-+99357 code, rather than modifier 21, provides more description. "The prolonged E/M service codes clarify whether it was face-to-face time with the patient and specify exactly the time parameters involved," explains Jennifer

Swindle, RHIT, CCS-P, CPC-EM-FP, CCP, director of coding compliance/charge entry for QLIMG, and director of the coding and compliance division of PivotHealth LLC in Garden City, N.Y.

Example: A visit, in which the E/M medical necessity level meets the criteria for 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed

history; a detailed examination; medical decision making of moderate complexity ... Usually, the presenting problem[s] are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family), takes 60

minutes of face-to-face time with the physician. This visit would be eligible for an additional prolonged service code 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 [List separately in addition to code for office or other outpatient evaluation and management service]) with 99214, Brown says. Expect an easier time getting paid for prolonged services that a physician provides face-to-

face to a patient. Most payers recognize prolonged services codes for direct patient care, but not for indirect care, Brown relays.

When billing prolonged services to inpatients whose insurers follow Medicare rather than CPT guidelines, a minor word change may force pediatricians to count time differently. Codes +99356 (Prolonged physician service in the inpatient setting,

requiring unit/floor time beyond the usual service; first hour [List separately in addition to code for inpatient evaluation and management service]) and +99357 (... each additional 30 minutes [List separately in addition to code for prolonged

physician service) now specify "unit/floor time" instead of "direct [face-to-face] contact." "If an inpatient needs a second assessment from a physician within the same group later in the day, you can capture all this time with the E/M service code,

plus the prolonged service code," said Peter A. Hollman, MD, AMA CPT editorial panel vice chair in the "Evaluation and Management Services" session at the CPT and RBRVS 2009 Annual Symposium in Chicago.

From the AMA's perspective, all the work the physician provides on the unit or floor providing E/M services for the patient can go toward face-to-face prolonged services, relates Hollman, who is the medical director for Blue Cross Blue Shield of

Rhode Island. "A physician can't just walk onto a unit and not see the patient."

Medicare, however, considers unit/floor time non-face-to-face, says William J. Mangold, Jr., MD, JD, medical director for Medicare Part B for Arizona and Nevada. For insurers that follow Medicare's time guidelines, you will count only the

documented time the physician spends face-to-face with the patient toward +99356 and +99357. "In pediatrics, Medicare guidelines are not directly applicable," points out Richard Tuck, MD, FAAP, a pediatrician with PrimeCare of Southeastern

Ohio in Zanesville. Therefore, you should consider the time for children floor time unless directed otherwise.