Pediatric Coding Alert

Account for extra service time with add-on codes

If your pediatrics practice isn't using prolonged service codes (99354-99359) for longer-than-usual evaluation and management (E/M) visits, you could be losing legitimate reimbursement money.
 
"Prolonged service codes are designed for pediatricians who spend an inordinate amount of time, specifically 30 minutes, greater than the AMA's stipulated time limit for a given level of E/M service," says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Penn.

Remember: Prolonged service codes are add-on codes, so they must be tagged to E/M services, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J. Do not report prolonged service codes alone, and never attach them to procedure codes.

Here is a closer look at the prolonged service codes, when to use them, and what your prolonged service claim should look like before sending it to the carrier. Prolonged Service Codes Depend on Setting Let's say the pediatrician performs a level-one E/M service on an established patient that takes 45 minutes. Level-one established patient E/M services typically take about 10 minutes, so a prolonged service code should accompany the E/M code on this claim. The claim should read:

 CPT 99201 -- Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a problem-focused history, a problem-focused examination, and straightforward medical decision-making

 +99354 -- Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting); first hour (list separately in addition to code for office or other outpatient evaluation and management service).  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:

 +99356 -- Prolonged physician service in the inpatient setting, requiring direct (face-to-face) patient contact beyond the usual service; first hour (list separately in addition to code for inpatient evaluation and management service) for the first hour.

 +99357 -- ... each additional 30 minutes (list separately in addition to code for prolonged physician service) for each additional half-hour. 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 [...]