Podiatry Coding & Billing Alert

Prone to using consult codes? Big mistake, says experts.

Don't think prolonged services have no great use to the podiatry practice. You can turn to this category of codes for patients who remain in the office for a prolonged period, and need intensive care -- such as a patient needing diabetic foot care. But first, what are the prolonged services codes?

• +99354 -- 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)
• +99355 -- ...each additional 30 minutes
• +99356 -- Prolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual service; first hour (list separately in addition to code for inpatient evaluation and management service)
• +99357 -- ...each additional 30 minutes.

Important: CPT uses the symbol "+" before a code to designate the code as an add-on code. Add-on codes do not take modifier 51 (Multiple procedures) and pay at 100 percent of the allowable for that code. Remember, you cannot reimburse prolonged services codes unless they are accompanied by the appropriate visit specific E/M codes.Coding prolonged services doesn't have to be a drag -- if you know the right questions to ask. The following FAQs should steer your claim in the right direction.

1. Does the Service Follow Time Requirements?

You should use prolonged services codes when a physician spends an inordinate amount of time (at least 30 minutes) greater than the AMA's time-limit guidelines for a given level of E/M service, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa. Here's the table to make the calculations:

                                                                                                          Total Duration of Prolonged Services Code(s)

                                                                                                                   (First 30 minutes not reported)

                                                                                                             30-74 minutes        99354 x 1

                                                                                                            75-104 minutes       99354 x 1 + 99355 x 1

                                                                                                            105-134 minutes     99354 x 1 + 99355 x 2

                                                                                                            135-164 minutes     99354 x 1 + 99355 x 3

                                                                                                            165-194 minutes     99354 x 1 + 99355 x 4

Example: A recently-diagnosed diabetic patient presents with an ingrown nail. The podiatrist documents the total duration of direct face-to-face services -- including the visit -- as 77 minutes. You should bill 99213 (Established patient, office or other outpatient visit), 99354, and one unit of 99355.

Heads-up: Medicare has scrapped consultation codes in 2010, and no longer accepts codes from 99241-99255 series. So, when you're billing Medicare, you'll have to find other codes to describe what used to be consults. Meanwhile, some non- Medicare payers continue to accept consultation codes.

2. Can You Fit a Time-Cumulative Scenario?

All prolonged services codes require "face-to-face" patient care, but that doesn't mean the time must be continuous.

Example: A podiatrist sees an established patient in a morning office visit for a level-three E/M to determine the cause of chronic heel and ankle pain. This visit lasts 20 minutes. At the end of the exam, the podiatrist orders an x-ray. The patient leaves to get the x-ray and returns that afternoon, and the podiatrist reviews the x-ray with the patient and discusses his diagnosis and treatment options. This visit lasts 30 minutes.

Code it: You would use 99213 and 99354 even though the time the podiatrist spent with the patient wasn't continuous.

Hint: Unlike a visit that's based on counseling time, the physician may not separate E/M and counseling time in the documentation for a prolonged services visit, but the documentation must justify the extra time. Be sure to document your face-to-face time precisely.

3. Should You Petition an Appeal For Denied Claims?

Medicare carriers pay for prolonged services in most areas, but not all carriers will be so quick to reimburse for prolonged services. Some areas would consider prolonged services a noncovered Medicare charge.

However, you always have the option to file for an appeal and you should when a case calls for it. You can take your case to the Qualified Independent Contractor (QIC) or administrative law judge level.