Primary Care Coding Alert

Hint: Don’t add up time for indirect care with face-to-face care.

When your clinician performs an E/M service, if your clinician is spending more time than is typical for that level of E/M service, you may be able to claim for this additional time and effort spent by your clinician by reporting an appropriate prolonged service code.

Since your FP usually performs E/M services in office, you will have to report these add-on codes for prolonged E/M services:

• +99354 (Prolonged evaluation and management or psychotherapy service[s] [beyond the typical service time of the primary procedure] 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 or psychotherapy service])
• +99355 (…each additional 30 minutes [List separately in addition to code for prolonged service]).

Follow these five tips to better understand whether or not you can report prolonged care codes in a particular » » situation and, if so, what codes you need to report depending on the duration of the session.

Tip 1: Follow CPT® Time Rules for Reporting Prolonged Services

When reporting prolonged services in addition to an E/M code, you will need to count the time your clinician spent face-to-face with the patient to analyze if you can report the prolonged service codes +99354 and +99355. “The insurance company would like to see actual minutes if possible (clock  time),” says Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, senior principal of ACE Med, a medical auditing, coding and education organization in Pittsburgh, Pa.“Otherwise, it must be very clear about how much time was spent in prolonged services. The documentation must also detail the facts about the visit that took longer.”

Even though the add-on prolonged services code +99354 contains a time descriptor as “first hour” of service, it is not necessary for your FP to have performed the prolonged service for one hour to report this code.

You will need to follow CPT® time rules to understand whether or not you can report +99354 for the extended period of time. According to the CPT® time rules, you can report +99354 when the extended E/M service lasts between 30-74 minutes longer than the typical time of the E/M code you are otherwise reporting. You report the add-on code +99355 in addition to +99354 when the session lasts between 75-104 minutes. For every 30 minutes of extended duration beyond 104 minutes, you report an additional unit of +99355.

“It must meet a minimum of 30 minutes beyond the typical time for the given CPT® code,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, PA. “For example, if the visit supports CPT® 99214, which has a typical time assigned by AMA of 25 minutes, then the provider needs to spend minimum of 55 minutes to begin billing prolonged service codes.”

“Prolonged services of less than 30 minutes are not separately reportable,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “Per CPT®, prolonged services of less than 30 minutes are part of the E/M code that you are otherwise reporting for the encounter.”

Tip 2: Report Base Code Only Once in One Day

When your FP performs an E/M service for an extended period of time, you report a prolonged care service code for the additional time spent. When reporting prolonged care services, you will have to report the base add-on code, +99354, only once for the patient on one calendar date of service. For any additional time spent beyond what is specified for +99354, you will have to report it with additional units of +99355.

The time spent by your clinician in performing the service need not be continuous. Even if your clinician is seeing the patient in split sessions, you still report +99354 only once on one date of service. You collate all the time spent in the various sessions to calculate if you can report +99354 and the additional unit(s) of +99355.

Note: Do not report the add-on code, +99355 without reporting the base add-on code +99354 for the first 30-74 minutes of prolonged services.

Tip 3: Prolonged Services Can be Reported with Any E/M Code

Some coders think that prolonged care services can only be reported with the highest level of E/M code, such as 99205 (Office or other outpatient visit for the evaluation and management of a new patient…) or 99215 (…anestablished patient…) for office services. However, this is not true. “You can report prolonged care services with any level of E/M code, but it’s important that the documentation support the reason why and give the details of the service” Hauptman adds. In order for you to report prolonged care services code such as +99354, your clinician should have performed the E/M service beyond the typical time stipulated in the descriptor for that particular E/M code.

For instance, the E/M code 99203 is typically performed for 30 minutes. When the session extends beyond this time, you can claim reimbursement for the additional time by reporting +99354 and +99355, as appropriate, according to the time spent.

Tip 4: Ensure to Include Proper Documentation

When reporting prolonged care services, you cannot just document time and report these add-on codes in addition to reporting the E/M code for the visit. In addition to documenting the correct time, you will need to provide added documentation to support your claim for these prolonged care codes.

You will need to include documentation letting the payer know why your clinician had to perform the extended service. You will need to include information that supports the medical necessity of performing a prolonged E/M service than is typical for the condition. Unless your documentation includes this information, just informing the payer about the time spent by your clinician might result in a denial of your claim for the prolonged services. “Your documentation should include not only the time spent but also what was done during that time that was necessary to provide the service,” Moore notes.

Tip 5: Check on Reporting Non Face-to-Face Prolonged Services

When reporting prolonged care service codes +99354 and +99355, you should remember that you can report these services only when your clinician is performing the E/M service face-to-face with the patient. You cannot count any time that you clinician spends non face-to-face with the time spent face-to-face. So, if your clinician spends time in the absence of the patient in going over records, being in conversation with other clinicians about the patient’s condition, or spending time reviewing reports, you cannot add this time into the time spent face-to-face with the patient.

“The descriptor for +99354 and, by extension, +99355, refers to the service ‘requiring direct patient contact’,” Moore points out. “Thus, the time counted must be face-to-face with the patient.”

However, you have a different set of add-on codes that you can try to report for these prolonged services that your clinician performed not being face-to-face with the patient. The add-on codes that you report for non face-to-face prolonged care services are:

• +99358 (Prolonged evaluation and management service before and/or after direct patient care; first hour)
• +99359 (…each additional 30 minutes [List separately in addition to code for prolonged service]).

As with face-to-face prolonged care services, you report the add-on code +99358 for the first hour of non face-to-face services that are provided to the patient and then report +99359 for every additional 30 minutes of service beyond the first hour.

Caveat: Many payers do not provide coverage for non face-to-face prolonged care service codes, +99358 and +99359. Check payer policies and coverage guidelines to see if these services are covered before you report these codes.

Medicare is one of the payers that has historically not paid separately for codes +99358 and +99359, considering payment for the codes “bundled” with the payment Medicare makes for other services. However, in the proposed rule for the 2017 Medicare physician fee schedule, the Centers for Medicare & Medicaid Services proposed to begin paying for these codes in 2017.

You can access the proposed rule online at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1654-P.html. CMS is expected to release the final rule, in which it makes its final decision on the status of these codes for 2017, on or around November 1, 2016.