Pediatric Coding Alert

Multiply your payment by ensuring your physicians are using their watch to note accurate E/M time.

It’s hard to imagine a specialty that spends more time talking to patients and their families than pediatricians, and it’s likely that you occasionally find the need to report prolonged service codes to reflect the time spent with patients above and beyond what the standard E/M codes include. But do you really know how to document these services to ensure prolonged service payment? Check out these tips for more information.

Break Down the Time Spent After the 30-Minute Threshold 

When you see a patient for an extended period of time and an office visit code alone doesn’t accurately represent the service he provided, you may be able to report an additional prolonged service code. You will choose from the following codes based on the place of service and the time spent: 

• +99354 (Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour …)
  
• +99355 (...  each additional 30 minutes …)
  

To determine the correct prolonged services code you should report, look at the time your provider spent on prolonged services with face-to-face patient contact. Without the reference time, there’s no way to define a service as prolonged. Refer to the quick reference table on page 93 to use the time spent during the service to determine the correct add-on code for the prolonged service.

Key: Any prolonged E/M service code is not reportable if the prolonged service is 30 minutes or less. In other words, your provider has to cross the 30-minute threshold of time before the prolonged services codes apply. So once the time with the patient goes over the threshold time, you can use a prolonged service code. If, however, the physician spends less than 30 extra minutes with a patient, you will not use +99354 or +99355. 

Example: A new patient comes into your office and you spend 90 minutes with her and her mother discussing the child’s recent diabetes diagnosis and everything that it will entail for her lifestyle and diet. Because most of that time was spent on counseling and coordination of care and your provider documented appropriately for time-based billing, you code 99205 (Office or other outpatient visit for the evaluation and management of a new patient …) for the E/M service that requires 60 minutes of face-to-face time with the patient. With a threshold of 30 minutes before the prolonged service code can be used, that 30 minutes is added to the required E/M service, leaving 30 minutes extra. Therefore, you can also report +99354 for this encounter.

Important: You can report only one unit of +99354 per date of service, but you can report multiple units of +99355 per day. You cannot report +99355 without first reporting +99354.

Count Contact Time on Same Day

When counting the time spent on an encounter for determining whether you can report a prolonged services code, the face-to-face patient contact doesn’t have to be continuous but it does have to be on the same day. 

Example: A physician sees an established patient during a morning office visit (99214, Office or other outpatient visit for the evaluation and management of an established patient, …25 minutes …) to determine the cause of chronic abdominal pain. This visit lasts 30 minutes. It is determined there are significant emotional, behavioral problems. Your schedule can accommodate an additional 30 minutes later in the same day. The patient returns in the afternoon. The pediatrician discusses and counsels on behavior management. This visit lasts 30 minutes.

Code it: You would use 99213 and add-on code +99354, even though the time the physician spent with the patient wasn’t continuous. 

Ensure You’ve Documented a Reason

To support your use of prolonged services codes, you should explain why the physician needed to provide a prolonged service. Just saying the physician spent 107 minutes with the patient isn’t sufficient enough to keep the claim from being denied when your payer asks for documentation to review. You need proof of medical necessity.

If you can’t report +99354 because of limited documentation, you may want to educate your physician on the monetary benefit to him if he better documents face-to-face time and medical necessity for extended encounters.

Consider Non-Face-to-Face Prolonged Services 

In some cases, you’ll report prolonged service codes even when part of your visit did not include a face-to-face service. CPT® includes two codes that apply to this scenario: +99358 (Prolonged evaluation and management service before and/or after direct patient care; first hour) and +99359 (…each additional 30 minutes [List separately in addition to code for prolonged services]). These descriptors mention “before and/or after direct patient care,” and therefore apply to the extra, non-face-to-face work that is often required before and after you see a patient.

Example: A parent presents with her infant who was just discharged from the neonatal intensive care unit. The child has Down Syndrome with a ventricular septal defect and congestive heart failure. Before the visit, you spend non-face-to-face time reviewing the extensive records that describe the baby’s condition and previous interventions. You perform a high level new patient visit (99205), and you then get on the phone and call the cardiologist to discuss the significant management of the patient’s congestive heart failure. You make an additional call to the home nursing service involved in caring for the infant. The cumulative time for non-face-to-face record review and phone time with the specialist is 35 minutes. You can therefore bill +99358 in addition to 99205. 

Here’s why: The reason you can report the non-face-to-face portion of the visit is because it involves a significant amount of time reviewing extensive records that goes far beyond a routine record review, and also includes phone calls to the specialists. This significant amount of non-face-to-face work went beyond what would be considered standard in an E/M visit and is therefore separately billable.

Tip: This non-face-to-face example, like all prolonged service codes, does not require a 25 modifier (Significant, separately identifiable evaluation and management. service by the same physician or other qualified health care professional on the same day of  the procedure or other service) on the base E/M code.