Primary Care Coding Alert

If you want to charge 99354 when your family physician (FP) treats asthmatic reactions, think again. Unless the FP spends 30 minutes past the E/M-defined time, reporting 99354 is overbilling.

You may think that prolonged services start with 30 minutes. But to use +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service first hour ), your FP has to provide a half-hour of face-to-face time with the patient beyond the usual time specified in the E/M code. Failing to follow CPTs time parameters will land you with overbilling or underbilling for your FPs time. So make sure youre not opening the door to an audit by coding the following example:

My FP sees a 10-year-old boy for an asthmatic attack on an emergency basis. She spends 30 minutes with the child and leaves the room. The nurse nebulizes him (94640). Then the doctor returns for two minutes and listens to his lungs following the nebulizer treatment. The physician wants to bill 99214 and 99354 for her time. Is this appropriate?

Bill 99214, 99354 When FP Spends 55 Minutes

In this case, because the physician spent only seven minutes over the usual time for 99214 (Office or other outpatient visit for the evaluation and management of an established patient physicians typically spend 25 minutes face-to-face with the patient and/or family), a prolonged service code (99354, +99355 each additional 30 minutes [list separately in addition to code for prolonged physician service]) does not apply, says Jaime Darling, CPC, certified coder for Graybill Medical Group, which has nine family physicians, in Escondido, Calif.

CPT guidelines stipulate that you should not use prolonged service codes for services lasting less than 30 minutes beyond the usual service, Darling says. So, you should report only the office visit code (99214) for the E/M service.

To report 99354, the FP would have to spend an additional 30 minutes past the time designated in the office visit code. CPT designates 25 minutes for 99214. Thus, you may report 99354 (30 minutes) with 99214 (25 minutes) when the FP spends a total of 55 face-to-face minutes with a patient on the same date of service, Darling says. According to CPT guidelines, the time does not have to be continuous. But it does need to be on the same date as the original E/M service, she adds.

In the asthmatic example, the FP spends a total face-to-face time of 32 minutes treating the patient, rather than the necessary 55. Thus, the visit does not qualify for 99214 and 99354.

Modifier -21 Applies to 99215, Not 99214

After billing 99214, you still have seven uncoded minutes (32 direct minutes - 25 minutes for 99214 = 7 leftover minutes), but no way to account for them. Although modifier -21 (Prolonged evaluation and management services) exists to report E/M services lasting less than an additional half-hour past the usual E/M time, modifier -21 does not apply in this situation.

CPT Appendix A, Modifiers, designates modifier -21 for the highest level of evaluation and management service within a given category, says Lynn M. Anderanin, CPC, senior coding consultant for Health Info Services in Des Plaines, Ill. So for an established office visit, you may use modifier -21 only with 99215 (Office or other outpatient visit ...).

Dont Forget 99058 for In-Office Emergency Care

You should report 99058 (Office services provided on an emergency basis) because the childs condition required the FP to interrupt her scheduled appointments to provide office services on an emergency basis, Anderanin says. Not all insurance carriers pay for 99058, but if they do, reimbursement is reasonable.