Pediatric Coding Alert

Question: During a scheduled office visit of an established patient, our physician spent additional office time evaluating the patient on top of the specified time for the primary visit. The visit was face-to-face for 30 minutes and then 74 minutes of additional face-to-face time. How do I code this?

Answer: You could use 99354 (Prolonged service 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 service]) for the first hour of the additional time. But because 99354 is an add–on code, payers will not reimburse you unless you report it with 

an appropriate primary code. A primary code such as 99201-99215 (Office or other outpatient visit…) or 99241-99245 (Office consultation for a new or established patient…). As described, you have provided 104 minutes of face-to-face time with the patient, in which counseling has dominated the visit. Therefore, you would report 99215 for an established patient to cover the first 40 minutes, as well as a unit of 99354 for the additional hour.

Note: The time used to report the total duration of face-to-face time spent by a physician or other qualified health care professional on a given date providing prolonged service in the office or other outpatient setting, even if the time spent by the physician or other qualified health care professional on that date is not continuous. The documentation should clearly indicate the total time and why it was needed. Keep in mind that you must spend at least 30 minutes of prolonged service time to bill the first hour using 99354.