Practice Management Alert

Know when not to use modifier 21

Is your practice walking away from reimbursement it's entitled to?
 
Billers that are not checking their physician's evaluation and management (E/M) notes for evidence of prolonged services could be leaving deserved reimbursement on the table.
 
When your physician provides services that take extra time, you can secure extra money -quot; in certain situations -quot; via the two prolonged services codes.
 
But there are very strict rules governing the use of prolonged services codes, and you cannot just use them each time your physician spends an extra minute or two with a patient.

Answer:

Remember that the setting matters when reporting prolonged services. According to CPT 2006:
 
- +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]) and +99355 (... each additional 30 minutes [list separately in addition to code for prolonged physician service]) are for office or outpatient settings.
 
- +99356 (Prolonged physician service in the inpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour [list separately in addition to code for inpatient evaluation and management service]) and +99357 (... each additional 30 minutes [list separately in addition to code for prolonged physician service]) are for hospital or inpatient settings.

The setting also comes into play when counting your physician's time. With prolonged hospital/inpatient services, the E/M can represent -floor time,- but the office/outpatient E/Ms must represent face-to-face time.
 
Important: Prolonged service codes are add-on codes, so you can tag them only to E/M services, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J.

Doctor Must Meet Time Requirement

Before deciding to use a prolonged services code, you must also figure out the total encounter time.
 
Why? Prolonged services codes are for instances when the physician spends an inordinate amount of time (at least 30 minutes) greater than the American Medical Association'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.
 
Example: The physician conducts a level-three evaluation and management service on an established patient in the office and spends a total of 35 minutes face-to-face with the patient. Since the physician spent only 20 minutes more than the AMA's time limit for 99213, you cannot report a prolonged service.
 
On the claim, you should report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components; an expanded problem-focused history; an expanded problem-focused exam; medical decision-making of low complexity) for the E/M service.

Exception: If the physician spent a total of 60 minutes face-to-face with the patient in the above example, you would:
 - report 99213 for the E/M service.
 - report 99354 second on the claim to account for the prolonged service time.

Important: Unlike a visit that's based on counseling time, the doctor isn't required to separate the E/M and counseling time in the documentation for a prolonged services visit. However, the documentation must justify the extra time.

Modifier 21 Is Only for High-Level E/Ms

When a visit does not meet the standards for prolonged services coding, you may be tempted to use modifier 21 (Prolonged evaluation and management services) to account for any extra E/M time. However, this is usually the wrong move, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, coordinator of HIM certificate programs at Clarkson College in Omaha.
 
Why? First, you can only use modifier 21 for top-level E/Ms. -That would be level five for office visits and consults, level three for inpatient admits and
subsequent visits, etc.,- Bucknam says. Also, -most insurers do not assign a specific increased reimbursement for modifier 21, so it won't help to round up any extra dollars for your practice,- Bucknam says.

-Face- Time Is Cumulative

All prolonged services codes require -face-to-face- patient care, but that doesn't mean the time must be continuous, Falbo says.
 
Example: A pulmonologist sees an established patient in a morning office visit for a level-three E/M that includes a chest x-ray review. This visit lasts 20 minutes. But the physician decides that the patient needs another x-ray. The patient leaves to get the x-ray and returns that afternoon, whereupon the pulmonologist reviews the x-ray with the patient and discusses treatment options. This visit lasts 30 minutes.
 
In this scenario, you could report 99213 and 99354, even though the time the pulmonologist spent with the patient wasn't continuous.
 
Another example of a patient who might not require continuous face time is a woman in labor, Bucknam says. -The physician would probably not stay with her continually, but his time could be added together for the total length of service,- she says.