Pediatric Coding Alert

Question: In the July issue of Pediatric Coding Alert, you recommended using modifier -21 for prolonged services. Can I append the modifier to any office visit code?

Illinois Subscriber

Answer: You may capture time spent beyond the typical time amount CPT allots for an E/M visit or consultation with the prolonged services modifier -21 (Prolonged evaluation and management services), provided you spend an extra 29 minutes or less on the visit.

However, you should only use the modifier on the "highest level of evaluation and management service within a given category," according to CPT 2002, Appendix A, page 381 [emphasis added].

Therefore, you may use the prolonged services modifier on codes for level-five office visits (99205, New patient; 99215; Established patient), initial hospital care (99223), subsequent hospital care (99233), outpatient consultations (99245), and inpatient consultations (99255, 99263). Notice that all of these codes are time-based codes, which specify typical times that physicians spend on these services. Codes that do not include time recommendations such as hospital observation services (99217-99220), and open-ended time codes such as hospital discharge day management code 99239 ( more than 30 minutes) do not qualify for modifier -21.

For instance, a pediatrician provides initial hospital care that meets the criteria for 99223. She spends 90 minutes with the patient, which is 20 minutes past CPT's allotted 70 minutes for 99223. Report 99223-21.

However, consider a pediatrician who spends 50 minutes discharging a patient. Code 99239 is open-ended. It states more than 30 minutes, which is an infinite amount of time. Therefore, modifier -21 is inappropriate.

For E/M time-based services that exceed 29 minutes, assign prolonged service codes as described in the July Pediatric Coding Alert article "Time Is of the Essence in ADD Evaluations."