Pediatric Coding Alert

Different staff has different CPT^® codes to report.

If your provider performs a prolonged, in-office evaluation and management (E/M) service with direct patient contact, coding isn’t as obvious as you might imagine.

Why? In-office prolonged service codes with direct patient contact are broken down by certain types of providers. If a physician or qualified nonphysician practitioner (NPP) provides prolonged E/M service, coding will differ than if another staff member performs the same service. Also, not all payers will accept all types of prolonged service codes.

Read on to get the lowdown on which prolonged service code each time a patient receives in-office prolonged E/M service from a provider at your practice.

Use These Codes When Physician, NP Performs Service

When the physician, or another billing provider such as a nonphysician practitioner (NPP), provides a prolonged E/M service with direct patient contact, you’ll report it with one of the following codes confirms Manny Oliverez, CEO of Capture Billing outside Washington, D.C.:

• +99354, Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service)  
• +99355, … each additional 30 minutes (List separately in addition to code for prolonged service)

Remember: You must report +99354/+99355 with an E/M service that has a time component, and the pediatrician must exceed the typical time of that E/M service by 30 minutes.

Example: The pediatrician performs an office E/M for a 7-year-old new patient. Encounter notes indicate that the pediatrician performed a detailed history and examination, along with low-complexity medical decision making (MDM), during the encounter. However, due to patient and parent concerns, the visit takes 64 minutes, all of which the pediatrician spends with the patient and her parents.

For this encounter, you should be able to report 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity) with 99354 to show that the service took at least 30 minutes more than the average 99203 visit. According to the 99203 descriptor, “Typically, 30 minutes are spent face-to-face with the patient and/or family.”

As long as you have documentation explaining why the visit took so much longer than the E/M level might indicate — and that the physician, or other qualified billing provider, provided the entire E/M service — then you could have a prolonged service claim on your hands.

Opt for +99415/+99416 on ‘Clinical Staff’ Prolonged Service

There is also another pair of codes for in-office prolonged E/M services with direct patient contact. When a staff member other than a billing provider performs the prolonged service, choose from the following codes:

• +99415, Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour (List separately in addition to code for outpatient Evaluation and Management service)
• +99416, … each additional 30 minutes (List separately in addition to code for prolonged service).

For coding purposes, billing providers are qualified healthcare providers such as physicians, NPPs, or nurse practitioners (NPs) that bill for their own services. The +99415/+99416 codes are for “prolonged service provided by clinical staff, but require that the physician or NPP be present to provide direct supervision of the clinical staff,” Oliverez explains.

Clinical staff prolonged service is a bit different than +99354/+99355 services. Like the +99354/+99355 codes, you must report these prolonged service codes along with an E/M service that has a time component.

You must be sure, however, that the billing provider performed and coded for the initial E/M service and the “clinical staff” provided the prolonged service. Also, you must exceed the typical E/M time by at least 45 minutes in order to consider coding +99415/+99416.

‘Clinical Staff’ Questions? Call Provider

A clinical staff member typically works under a physician or other qualified health care professional. Clinical staff must be cleared by law, regulation, and facility policy to perform or assist in the performance of a specified professional service. The difference is that clinical staff would not individually report the service; instead, they would report the prolonged service code under the supervising provider’s billing number.

Who’s clinical staff? A medical assistance (MA) provider, registered nurse (RN), or licensed practical nurse (LPN) would be clinical staff. A physician assistant (PA) or NP would not be clinical staff.

The rules as to who is “clinical staff” could vary by state and by payer, however. If you have any doubt as to your states, or payer’s, specific definition of clinical staff, be sure to check state laws or consult a payer representative before considering +99415/+99416.

Downside: Since clinical staff doesn’t have billing privileges, you might not get paid for +99415/+99416, says Suzan Hauptman, CPC, CEMC, CEDC, senior principal of ACE Med group in Pittsburgh, Pa. “Individual payers will decide on whether to cover these [codes] or not,” she says.

Takeaway: If clinical staff provides prolonged E/M service with direct patient contact, it can’t hurt to report the +99415/+99416 codes. Just don’t expect perfect payment results, as payers’ policies are still evolving around these codes.