Primary Care Coding Alert

Documentation of physician time is critical in charging for prolonged services, which are face-to-face, as is the evaluation and management (E/M) code for outpatient care, says Barbara Cobuzzi, CPC, CHBME, president of Cash Flow Solutions, a medical billing and consulting firm in Lakewood, N.J.

E/M codes used in the inpatient environment are based on time spent on the patients hospital floor or unit, so when using prolonged services with inpatient E/M codes, remember that face-to-face time must be at least 30 minutes, she explains.

During an office or other outpatient visit for the E/M of a new patient 99201-99205 (which require three key components: ranging from a problem-focused to comprehensive history, a problem-focused to comprehensive examination and straightforward decision-making to one of high complexity), physicians typically spend 10, 20, 30, 45 and 60 minutes face-to-face with patients for each of the five levels of E/M service. When direct contact with the patient exceeds the standard amount of time by 30-60 minutes on a given date, you may use 99354 (prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour) in addition to the E/M code.

The same rules apply to inpatient services, 99221-99223 (initial hospital care, per day, for the evaluation and management of a patient which requires these three key components: ranging from a detailed to a comprehensive history, a detailed to a comprehensive examination and medical decision-making that is straightforward or of low complexity to one of high complexity). In coding for these three levels of inpatient service, a prolonged service code, 99356 (prolonged physician service in the inpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., maternal fetal monitoring for high-risk delivery or other physiological monitoring, prolonged care of an acutely ill inpatient]; first hour) may only be used if physicians spend 60, 80 or 100 minutes, respectively, at the bedside and on the patients hospital floor or unit.

If outpatient services exceed 74 minutes beyond the typical time allotted for each E/M level, code 99355 (each additional 30 minutes) in addition to 99354. On the inpatient side, code 99357 (each additional 30 minutes), in addition to 99356.

Scenarios for Using Prolonged-Service Codes

Scenario #1: A 35-year-old established female patient with diabetes visits her FP for a three-month check-up to review her diet, lifestyle and medications, which takes 35 minutes. Her blood sugar is out of control, so the FP spends a total of an hour with the patient. The FP should code 99214 (office or other outpatient visit for the evaluation and management of an established patient which requires at least two of these three key components: detailed history, detailed examination and medical decision-making of moderate complexity). CPT also states that for 99214 usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family. Cobuzzi reminds FPs that even if the visit did not entail two of the three components, time is the element which makes 99214 appropriate. Since the visit took an hour, the FP also may code 99354.

Note: Previously, modifier -21 (prolonged evaluation and management services) may have been used instead of 99354, but it predates the prolonged service code and is rarely used, says Tom Kent, CMM, principal of Kent Medical Management, a medical office management and coding consulting firm in Dunkirk, Md.

On page 8, CPT 2000 states: When counseling and/or coordination of care dominates (more than 50 percent) of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time may be considered the key or controlling factor to qualify for a particular level of E/M service.

Kent notes, that if the time requirements are met, you could choose to code 99215 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history, a comprehensive examination and medical decision-making of high complexity), a higher level of office visit, without the prolonged service code. By not using 99354, there is a better chance of getting paid without having to face an appeal, he says. Using the lower level for the office visit with the prolonged service code will entail careful documentation to support the care that is given.

Make sure that the complexity and management of the problem meet the E/M level and that time is considered prolonged, says Victoria Jackson, CEO of South Orange County Pediatrics, a 10-physician practice in Lake Forest, Calif., You have to justify what was done but also indicate the amount of time spent with the patient.

Doctors are missing an opportunity if they dont document the time spent with the patient making it possible to code a higher level of E/M service, Cobuzzi adds.

Scenario #2: A critically ill 50-year-old male patient with acute asthma visits his FP in her office but is immediately admitted to the hospital. You would code 99222 (initial hospital care, per day, for the evaluation and management of a patient which requires these three key components: a comprehensive history, a comprehensive examination and medical decision-making of moderate complexity)during which physicians typically spend 50 minutes at the bedside and on the patients floor or unit.

The entire time for the office visit and admission to the hospital takes three hours, with the time spent in the office and the wait for the ambulance consuming a half-hour of that time. In addition to 99222, you should code 99356 for the first hour beyond the half-hour and 99357 three times for the next three increments of 30 minutes. Per CPT, that is how you code for prolonged service between 135 and 164 minutes. The time doesnt have to be continuous, Kent says.

Cobuzzi reminds FPs not to code for the office visit too. According to CPT, all the E/M services done by that FP on the date of admission are considered part of 99222.

Scenario #3: An established 45-year-old patient experiences abdominal pain and is evaluated in the FPs office. He is given a workupperhaps a hemogram (85022), which is a platelet countand prescribed medicine, after which he goes home. The FP calls later to discuss the problem and to see if the medication is working. Due to the lab tests, the visit may constitute moderate decision-making, so it would be appropriate to code 99214. While 99358 (prolonged evaluation and management service before and/or after direct [face-to-face] patient care [e.g., review of extensive records and tests, communication with other professionals and/or the patient/family]; first hour) may make sense, Medicare wont recognize the code because the extra time spent in evaluating the tests and talking to the patient are considered part of the office visit.

Jackson strongly encourages coders to use 99358 and 99359 (prolonged evaluation and management service before and/or after direct [face-to-face] patient care [e.g., review of extensive records and tests, communication with other professionals and/or the patient/family]; each additional 30 minutes) even though Medicare is likely to deny it. If you can document services above and beyond the E/M level of service, send the report to Medicare, she says. You can always appeal the decision if you are denied. If you walk away, Medicare will get what it wants and not have to follow the CPT guidelines. The CPT book is written for a reason. Many people code from a comfort level but you have to utilize the codes to their fullest potential or you will be doing the FP a disservice and setting a precedent.

Telephone Calls Add To Time Spent Although telephone calls, 99371-99373 (telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other health care professionals [e.g., nurses, therapists, social workers, nutritionists, physicians, pharmacists]; simple or brief [e.g., to report on tests and/or laboratory results, to clarify or alter previous instructions, to integrate new information from other health professionals into the medical treatment plan, or to adjust therapy) often consume an FPs time, none of these telephone codes will be recognized by Medicare. Codes 99372 and 99373 apply to intermediate and complex or lengthy telephone calls. Tom Kent, CMM, principal of Kent Medical Management, a medical office management and coding consulting firm in Dunkirk, Md., describes a scenario that would indirectly pay for phone calls. The FP receives a call from a panicky 61-year-old established female patient who has a fever and nausea. The FP reassures her and suggests she come into the office later that same day. While the FP cant bill for the earlier call, he can document the discussion in the patient record and use it as part of the history. In this way, the history may become more complex and bump up the level of the office visit. Note: Dont use codes for prolonged services willy-nilly, Barbara Cobuzzi, CPC, CHBME, president of Cash Flow Solutions, a medical billing and consulting firm in Lakewood, N.J., warns. That could raise a red flag. She does point out that FPs are responsible for the whole patient, making it easier to document and spend more time with each person. She also recommends carefully clocking specific start and stop times of care and including that information in the documentation.