Eli's Rehab Report

Nugget: Many coders dont use prolonged service codes for fear of an audit, but downcoding results in loss of reimbursement as well as being a red flag for an audit.

Use the prolonged service codes (99354-99357) to avoid writing off the expense of spending extra time with patients during office or inpatient visits, says Ron Nelson, PA-C, an advisor to the American Medical Associations CPT healthcare professionals advisory committee for the American Academy of Physician Assistants, and president of Health Services Associates, a consulting firm in Fremont, Mich.

CPT 2000 lists typical amounts of time that physicians spend on evaluation and management (E/M) services. For example, a level-four visit for a new patient (99204) normally takes about 45 minutes. When a physician provides services that take significantly longer than the typical 45 minutes for this level of E/M, they can add on the appropriate prolonged service code, which in this case would be 99354 (prolonged physician service in the office or other outpatient setting requiring direct, face-to-face contact beyond the usual service; first hour). This code, depending on the patients Medicare fee schedule, normally pays about $75, says Joan Everson, office manager at Bay Area Rehabilitation in San Francisco.

But we usually up the code, rather than using prolonged service codes, says Everson. If it was going to be the level-two E/M code, we would up it to a level-three. We dont make the decision ourselves, the doctor marks which E/M code we should bill on his form.

Reluctance To Use Prolonged Service Codes

Most coders seem to avoid using the prolonged service codes because they dont want to give Medicare any reason for an audit. We tend to bill the highest level of E/M code for the services the doctor is providing, says Karen Lawrence, owner of Anesthesia Resource Network, a billing firm in Kennesaw, Ga., that handles the billing for four inpatient physiatry practices. When you bill the prolonged service codes, you end up having to send documentation [that] a clerk at the other end is reviewing. We dont want to set off any alarms with that clerk, so we come as close as we can to the time the doctor spends with the patient by using the E/M codes.

Debbie Brooks, business manager at the office of D. Wayne Brooks, MD, a PM&R physician in Springdale, Ark., agrees. We dont bill for the extra time spent because all it does is red-flag Medicare. So, unfortunately, we probably undercode to avoid alerting Medicare. We just collect for the highest level of E/M code that applies to the service.

But downcoding can send up red flags with Medicare, too, says Nelson. Unless someone has a concern that what theyre doing is incorrect, they should use the prolonged service codes when appropriate. These codes and this system is designed to ensure that you appropriately document and bill and get paid for what you provide.

Nelson also has this word of caution: By the same token, there is a requirement that you not underbill. If your records reflect a greater documentation, but you write it off for Medicare and then bill, for example, a workers compensation carrier for the prolonged service, then youve got a problem, because youre downcoding for Medicare and not applying a uniform fee schedule. A lot of people dont understand that downcoding can be just as hazardous as upcoding.

When using the prolonged service codes, billers should always bill for the proper amount of time spent, and retain all backup information. Susan Beach, office manager in the office of Jorge Minor, MD, a PM&R doctor in Los Angeles, reports successfully using under appeal a prolonged service code for a patient receiving a prosthetic. Nelson applauds her appeal. The more you use the codes and the reviewers see that theyre being used appropriately, the more the payers are going to say that these codes are working properly, Nelson says. Not using the codes is doing a disservice to those people who are truly using the prolonged services.

CPT 2000 states that prolonged service codes can only be used when the doctor spends at least 30 minutes more than the usual amount of time allowed for E/M services. The prolonged service codes are add-on codes, which means that they must be reported along with their corresponding CPT code to ensure payment. Section 15511.1 of the Medicare Carriers Manual, Part 3 outlines the appropriate add-on codes that correspond to the E/M codes. For example, 99354 should be used with the following add-on codes:

office or other outpatient services (99201-99215)

office or other outpatient consultations
(99241-99245)

comprehensive nursing facility assessments
(99301-99350)

CPT code 99356 (prolonged physician service in the inpatient setting, requiring direct, face-to-face patient contact beyond the usual service) should be used with the following add-on codes:

hospital inpatient services (99221-99233)

initial inpatient consultations (99251-99255)

follow-up inpatient consultations (99261-99263)

The Medicare Carriers Manual also points out that the prolonged service codes are billable for direct face-to-face contact between the physician and the patient whether the service was continuous or not. Physicians should document all of the time they spend with the patient, even if they are coming in and out of the examining room at separate intervals.