Pediatric Coding Alert

Go beyond reporting time to claim additional service time successfully.

You’ve probably coded more evaluation and management (E/M) sessions that have gone beyond the time parameters of 99201 through 99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) than you care to remember. After all, counseling and working with patients with chronic or complex conditions often takes up a lot of your provider’s time. Then there’s all the research and record reviews that go on behind the scenes that you have to account for.

But are you doing it correctly? Are you coding face-to-face visits according to the time thresholds established by CPT^®? Moreover, are you providing sufficient documentation for work your provider does when the patient is not present? Before you code your next prolonged care session, make sure you read this timely advice.

Hint 1: Remember This Face-to-Face Rule

You’re probably familiar with the four prolonged face-to-face care codes:

• +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)
• 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).

You’re probably also aware that you’ll need to use +99354/+99355 when the direct patient contact is provided by “a physician or other qualified health care professional,” according to CPT^® guidelines. But if you use +99415/+99416, you’ll need to document that the service was provided “by clinical staff under the direct supervision of a physician or qualified health professional,” according to Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Hint 2: Thresholds Key to Accurate Time Coding

Second, you need to make sure you calculate time correctly and “be aware of the different time thresholds. Prolonged time of less than 30 minutes for the physician codes or 45 minutes for the clinical staff codes is not separately reportable,” Moore reminds coders. This means you must be able to document an additional 30 to 74 minutes for +99354, an additional 45 to 74 minutes for +99415, and any additional time between 15 and 44 minutes with added units of +99355 and +99416.

Under these circumstances, when you “report prolonged services, your time documentation needs to be precise. It should include details of important clinical matters — what happened in that face-to-face encounter — and it should also support coding,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

Hint 3: Know How and When to Use Non-Face-to-Face Prolonged Codes

You can also document services your provider performs when the patient is not present with two more codes:

• 99358 — Prolonged evaluation and management service before and/or after direct patient care; first hour
• +99359 — … each additional 30 minutes (List separately in addition to code for prolonged service).

Per the Centers for Medicare and Medicaid Services (CMS), you can report 99358/+99359 providing you can document “prolonged communication consulting with other health care professionals related to ongoing management of the patient, prolonged review of extensive health records, and diagnostic tests regarding the patient,” according to Falbo. And, per CPT^® guidelines, the services must “relate to a service or patient where (face-to-face) patient care has occurred or will occur and relate to ongoing patient management.”

But there are also some pretty important caveats to these guidelines that you will need to take into account. You cannot use these codes for “time spent in care plan oversight services … home and outpatient INR [International normalized ratio] monitoring … medical » » team conferences … online medical evaluations … or other non-face-to-face services that have more specific codes and no upper time limit,” according to CPT^®.

The time thresholds, however, remain the same as the face-to-face prolonged care codes. So, you can use 99358 to document the 30 to 74 minutes of non-face-to-face care and report additional units between 15 and 44 minutes with +99359. “The same rules as +99354/+99355 and +99415/+99416 apply, only you don’t have to substantiate direct patient contact,” Falbo reminds coders.

Hint 4: Use Prolonged Care Codes Sparingly

You should only use prolonged service codes to document “unusual circumstances that go above and beyond the typical or average time of the documented visit code.” To do that, Falbo concludes, “it is important that you record the times for these time-based codes in the medical record.” It is also important to remember that prolonged care face-to-face codes cannot be used if the initial time assessed to the base code has not been met. For example, you would have to have 55 minutes at a minimum to bill a 99214 (25 minutes) with a +99354 prolonged care code for the additional 30 minutes.