Pediatric Coding Alert

Prolonged service codes are add-on codes designed to capture extra time spent on an E/M service that takes at least 30 minutes longer than the CPT-recommended time,  Brink says. Use 99354 for the first hour of outpatient prolonged service time and +99355 (... each additional 30 minutes [list separately in addition to code for prolonged physician service]) for each additional half-hour for outpatients.

If, however, the prolonged service takes place in an inpatient setting, use:

Remember: In order to use the first-hour prolonged service codes, you must provide at least 30 minutes of prolonged service time beyond the CPT-allotted time for that E/M service. If you haven't met that requirement, the prolonged service codes are not applicable.

In general, you should not upcode the level of E/M service based on time; only raise the level of E/M service if the pediatrician provides a higher level of service. "If the physician is performing a level-four new patient E/M service, report that service (99204) and an add-on code,"  Brink says.

Exception: If, however, the pediatrician spends more than 50 percent of the face-to-face time counseling and coordinating care, the E/M service can be raised based on time, Falbo says. For example, if the pediatrician's notes indicate that he performed a level-four established patient E/M service in the office that took 80 minutes and he spent 45 of those minutes counseling the patient, you would report the level-five E/M code (99215) and a prolonged service code (99354). Include specific documentation on the 45 minutes of counseling to strengthen your claim.

Face-to-Face Time Is Cumulative, Not Continuous

All of these prolonged service codes require "face-to-face" patient care, meaning that the pediatrician must have interacted with the patient/patient's parents exclusively during the prolonged service time. But that doesn't mean the time must be continuous.

"It doesn't have to be one long face-to-face session," Falbo says. A pediatrician can provide prolonged service in different time segments during the course of a day, she says.

Example: A pediatrician giving a nebulizer treatment to an asthmatic patient spent 50 minutes visiting with the patient initially, then had the patient stay for observation while he tended to other matters.

An hour later, the pediatrician returned to the patient and spent another 40 minutes explaining the results to the patient and discussing treatment options with the parents.

The claim for this example should read:

 

Explanation: The pediatrician spent a total of 90 minutes on the E/M service, far beyond the 40 required to report 99215. Appending 99354 helps your office recoup money for the extra time the pediatrician had to dedicate to performing the service. As long as the time is properly documented, the prolonged service code is admissible.

Strong Documentation Drives Proper Claims

As with reporting critical care, successful prolonged service coding must feature down-to-the-minute documentation. If you don't have time on your side, prolonged service coding can become one extended headache.

"The key to prolonged service claims is making sure you have the documentation to reflect the extra time the service took," Brink says. Without it, experts say, your claim stands a slim chance of acceptance.

"The pediatrician must document the start and stop times of prolonged care, and demonstrate what he or she did during prolonged service time," Falbo says. "This documentation substantiates, in the medical record, that they did spend the 30 minutes or more" required for the first-hour prolonged service codes.

Timekeeping is even more critical when reporting prolonged service codes and procedure codes on the same claim. "Carve out the time spent on the procedure before reporting prolonged services," Falbo says.

Remember: When reporting prolonged service codes and procedure codes on the same claim, make sure you are coding the total E/M time, not the total time of the visit. Deduct the time spent on the procedure from the prolonged service time, or your office could be in trouble. "Make sure your notes clearly document that you haven't 'double-dipped' into the time spent doing the procedure," Falbo says. "You can't bundle the procedure time into the prolonged service time."