Primary Care Coding Alert

Question: A level four office visit with an established patient took 55 minutes of physician-patient face-to-face time due to the service involving an interpreter, which the patient and family required to converse with the family physician. The family physician wants to code 99214 and prolonged services. Is this appropriate?

Answer: Yes, you may use a prolonged service code in this situation because the time thresholds for billing both 99214 (25 minutes) (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. . . . Physicians typically spend 25 minutes face-to-face with the patient and/or family) and 99354 (30 minutes more than 99214) (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]) have been met. Documentation must also establish the medical necessity for the service.

If you're worried that a payer will consider an interpreter insufficient cause to bill prolonged services, here's the support you need. Use one Medicare carrier's policy to appeal for coverage from your third party payers. In the case of an interpreter causing a service to take longer than usual, "the medical necessity for the prolonged care was valid because of the patient's inability to communicate," according to Palmetto GBA's (Part B Medicare carrier for Ohio) Frequently Asked Questions (http://www.littleurl.net/dbb8f0).