Pediatric Coding Alert

Question: One of our asthmatic patients was in the hospital for over a week with pneumonia and after discharge, she came to our office. What is the best way to code for an extended office visit following an acute hospital stay? The physician spent a great deal of office time with the patient and her family, reviewing the hospital notes and medication lists. He thinks there is a special code for billing these types of visits. Can you help?

Answer: If you’re billing based on time, you may be able to bill based on time, or report prolonged care for the office visit (+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]). If the physician’s prolonged time went beyond an hour, check whether you can also submit +99355 (…each additional 30 minutes [List separately in addition to code for prolonged service]). Note that prolonged service of less than 30 minutes on a given date is not separately reportable.  

Key: The physician needs to document the time, such as with a statement similar to, “I spent ___ minutes face to face with the patient. We discussed ______.” That helps your coding, plus gives the documentation necessary during an audit. You’ll also report the appropriate office visit code, since +99354 and +99355 are add-on codes billed in addition to the E/M office visit code, in this case at a high level 99214 or 99215. No modifier is necessary when you bill the prolonged services code with the E/M code.

Coders sometimes think the patient must be in the hospital or nursing facility to use the prolonged services codes, but that’s not the case. There are inpatient and outpatient prolonged service codes. You can report +99354 and +99355 for any extended office or outpatient evaluation and management (E/M) service, if you have sufficient documentation of the time. Some patients with complex conditions or multiple health concerns require more time than others. Prolonged service codes can apply if the physician documents the total time spent with the patient and what was discussed, and it is 30 minutes or more than the typical time associated with the base E/M code. There are also prolonged services codes for before/after the face to face visit, which may be appropriate to review extensive records and make related calls.

Example: Let’s say that in your physician’s situation that the encounter otherwise merits reporting a 99214 based on the history, exam, and medical decision making involved in the encounter. That code has a typical time of 25 minutes in CPT^®. However, because of the need to review the hospital notes and medication lists with the patient and family in this case, let’s say the physician actually spent 60 minutes in the visit. In that scenario, the prolonged time is 35 minutes (60 - 25 = 35), which exceeds the 30 minute threshold for reporting prolonged services and is enough to justify reporting +99354. The principle works the same way if the level of service for the visit code is chosen on the basis of time (i.e. because the encounter was dominated by counseling and coordination of care).

Keep in mind: The new transitional care management codes 99495 and 99496 could apply to this case as well, depending on how well the documentation meets the requirements of these new codes.