Primary Care Coding Alert

Many coders are confused about when to code for time and when to use the prolonged service codes. When an E/M visit exceeds the standard amount of time by 30 minutes or more, physicians should use the prolonged service codes (99354-99357) in addition to the E/M code.

"You code based on time when counseling or coordination of care dominates (i.e., consumes more than half the face-to-face time) the encounter in the office," says Kent Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians. "When that happens, you code based on total time the physician spent with the patient compared to typical time in CPT." Thus, if a visit spent predominantly in counseling or coordination of care meets or exceeds the typical time for an E/M service, e.g., 99215 (physician usually spends 40 minutes), report that code. "The prolonged services codes, on the other hand, allow you to capture time over and above the typical time when you are coding the E/M based on history, exam and medical decision-making," Moore says.

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 [list separately in addition to code for office or other outpatient evaluation and management service]) when an office visit is 30 to 74 minutes longer than the typical time for that service. If the service surpasses 74 minutes beyond the typical time allotted for each E/M level, use +99355 ( each additional 30 minutes [list separately in addition to code for prolonged physician service]) in addition to 99354.

"The prolonged service must be face-to-face with the patient," says David Berland, MD, the AMA CPT adviser for the American Academy of Child and Adolescent Psychiatry. "If the doctor is taking extra time during a visit, but coming in and out of the exam room, or leaving that patient with a nurse for periods of time, the prolonged service codes cannot be used.

"Do not report a prolonged service time of less than 30 minutes," Berland says. "It is included in the E/M code." Subtract the typical time for the E/M visit from the total time spent with the patient. If the remainder (i.e., the prolonged part) is 30 minutes or greater, use a prolonged service code. For example, if the doctor spent 55 minutes in a 99215, the typical time for which is 40 minutes, the prolonged part of 15 minutes cannot be separately reported.

The following vignettes illustrate appropriate use of the prolonged service codes:

Case #1: A new female patient presents with allergies. After performing an evaluation, the family practitioner (FP) tests for allergies using skin tests with allergenic extracts and a delayed reaction. The patient is directed to wait in the waiting room for 30 minutes to determine if she has an allergic reaction to the extracts. Fifteen minutes after the injection, the patient complains of tightness in her throat. Her face is flushed. She begins to cough and wheeze and becomes short of breath. The FP takes her into the treatment room and evaluates her condition. The physician gives her another injection to counteract the reaction and periodically evaluates the patient's response to the medication. After several evaluations, the doctor determines that the patient is stable, and she is allowed to go home. The FP has spent 30 minutes evaluating and treating the patient's response.

Coding #1: Use 99203 for the E/M office visit. For a level-three office visit, the physician usually takes at least a detailed history and exam of a new patient, and the medical decision-making is of low complexity. Code 99354 for the additional 30 minutes spent in prolonged service. You should also report 95028 (Intracutaneous [intradermal] tests with allergenic extracts, delayed type reaction, including reading, specify number of tests) for the allergy testing and the appropriate code(s) for the type of injection given to counteract the reaction. Link 995.3 (Allergy, unspecified) to the E/M codes.

Case #2: An established male patient periodically has an acute asthmatic attack. Based on the patient's history, the FP treats him in the office for the attacks. When the patient presents with an acute attack, the doctor performs an E/M service based on the patient's presenting symptoms only. Because the FP knows the patient well, he or she does not need to perform the highest level of established office visit to treat the acute asthma attack. To treat the asthmatic attack, the FP and office staff initiate therapy with vasodilator drugs and bronchodilators via an inhaler. The physician evaluates the patient's breath sounds at various intervals to determine the effectiveness of the treatment. An hour and a half later, once the acute attack is over and the patient's condition is stable, he is allowed to leave the FP's office without going to the emergency department. Before the patient leaves, the doctor counsels him briefly about his condition and the effects of the medication prescribed to treat the attack.

Coding #2: If the physician's face-to-face time with the patient didn't meet the threshold for prolonged services, the doctor could only bill the appropriate level of E/M code in this case, 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...). Because the visit was based on the patient's presenting symptoms only, the history portion of the E/M visit consisted of a problem-focused history, an expanded problem-focused exam (constitutional plus respiratory systems, at a minimum), and medical decision-making of at least low complexity (based on an established problem uncontrolled, with no tests ordered and moderate risk). Also, report 94640 (Nonpressurized inhalation treatment for acute airway obstruction) for the inhaler treatment with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to the E/M code. Use 493.92 (Asthma, unspecified, with acute exacerbation) for the asthma attack.

Case #3: An established patient with a long history of migraines presents with a migraine attack. The FP has treated this patient in the past, and she has responded to Compazine infusion. The FP starts an IV and runs Compazine through it. It takes the FP 45 minutes to set up the IV, administer the drug, monitor the patient and evaluate the effectiveness of the treatment.

Coding #3: Use 99213 for the E/M office visit. For an established patient with a previously diagnosed problem, the FP would most likely take a problem-focused history, expanded problem-focused exam (e.g., constitutional plus neurological systems, at a minimum), and medical decision-making of at least low complexity (based on a previously diagnosed problem that is not controlled, no tests ordered, and moderate risk). Code the 30 minutes of prolonged service beyond the typical E/M time with 99354. Also bill 90784 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; intravenous) for the IV injection and J0780 for the Compazine. For the migraine diagnosis, use 346.9x (Migraine, unspecified) linked to both CPT codes.

Case #4: An established patient who works outside presents with symptoms of heat exhaustion consisting of dehydration and elevated temperature. The FP spends an hour evaluating the patient and determines he has serious heat injury. The physician administers two liters of fluid and checks the patient's condition with a urine test and blood work.

Coding #4: Use 99213 for the E/M. This visit would most likely include at least a problem-focused history and an extended problem-focused exam because the FP is likely to check at least two systems, such as constitutional and cardiovascular or respiratory. The medical decision-making is of low complexity. Although it's a new problem with additional workup, the amount and complexity of data are minimal, and the risk, according to the E/M documentation guidelines, is low. Report 99354 for the 60 minutes of prolonged service. Also, include a code for the urinalysis (e.g., 81002) and the other blood tests (e.g., complete blood count, 85022-85025). If the fluids are administered by IV, the coder should use 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) in lieu of 99354. Use 992.5 (Heat exhaustion, unspecified) or 992.3 (Heat exhaustion, anhydrotic) for heat exhaustion due to water depletion.

Case #5: An established patient undergoing a major crisis presents to the FP. His co-worker and close friend committed suicide. The patient is physically and mentally distraught. The FP counsels the patient for an hour and eventually calls the patient's wife in.

Coding #5: Code the E/M as 99215 based on time because the entire hour was spent counseling the patient. The prolonged service codes would be inappropriate in this case. The diagnoses might include 309.0 (Adjustment reaction; brief depressive reaction) and V65.49 (Other persons seeking consultation without complaint or sickness; other counseling, not elsewhere classified; other specified counseling) for the grief counseling provided by the FP.