Pediatric Coding Alert

Question: A level four office visit took 55 minutes of physician-patient face-to-face time due to the service involving an interpreter, which the patient and family required to converse with the pediatrician. The pediatrician wants to code 99214 and prolonged services. Is this appropriate?

Ohio Subscriber

Answer: Yes, you may use a prolonged service code in this situation because the time thresholds for billing both 99214 (25 minutes) (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually, the presenting problem[s] are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family) and 99354 (30 minutes more than 99214) (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management service]) have been met. Documentation must also establish the medical necessity for the service.

If you're worried that a payer will consider an interpreter insufficient cause to bill prolonged services, here's the support you need. Use one Medicare carrier's policy to appeal for coverage from your third party payers. In the case of an interpreter causing a service to take longer than usual, "the medical necessity for the prolonged care was valid because of the patient's inability to communicate," according to Palmetto GBA's (Part B Medicare carrier for Ohio) Frequently Asked Questions (http://www.littleurl.net/dbb8f0).

You'll note in the question the prolonged services code is not applied to the highest code in the category (99215). This is consistent with proper use of the prolonged services codes. Prolonged services codes can be used with E/M services codes of any level provided the code includes a time designation.