Pulmonology Coding Alert

Pulmonology providers who write off the expense of spending extra time with patients during office or inpatient visits could be using the prolonged service codes
(99354-99357) to increase reimbursement, says Ron Nelson, PA-C, an advisor to the AMA CPT Healthcare Professionals Advisory Committee for the American Academy of Physician Assistants, and President of Health Services Associates, a healthcare consulting firm in Fremont, Mich.

CPT 2000 lists typical amounts of time that physicians spend in evaluation and management (E/M) services. For example, a level-four office visit for a new patient (99204) normally takes about 45 minutes. When a physician provides services that take significantly longer than the typical 45 minutes for this level of E/M, he or she can add the appropriate prolonged service code, which in this case would be CPT 99354 (prolonged physician service in the office or other outpatient setting requiring direct, face-to-face contact beyond the usual service; first hour). This code, depending on the patients Medicare fee schedule, normally pays between $75 and $125.

Reluctance to Use Prolonged Service Codes

Many pulmonology coders avoid the prolonged service codes because they dont want to give Medicare a reason to audit them. We tend to bill the highest level of E/M code for the services the doctor is providing, says Karen Lawrence, owner of Anesthesia Resource Network, a billing firm in Kennesaw, Ga. When you bill the prolonged service codes, you end up having to send documentation, and a clerk at the other end will review it. We dont want to set off any alarms with that clerk, so we come as close as we can to the time the doctor spends with the patient by using the E/M codes.

According to Nelson, however, downcoding can be just as likely to send red flags to insurers. Unless someone has a concern that what theyre doing is incorrect, they should use the prolonged service codes when appropriate, says Nelson. These codes and this system are designed to ensure that you appropriately document and bill, and get paid for what you provide. By the same token, there is a requirement that you not under bill. If your records reflect more time, but you write it off for Medicare and then bill, for example, a workers compensation carrier for the prolonged service, youve got a problem. Now youre downcoding for Medicare and not applying a uniform fee schedule. A lot of people dont understand that downcoding can be just as hazardous as upcoding.

When using the prolonged service codes, coders should bill for the proper amount of time spent and retain all backup information. Supporting documentation should be on hand for Medicare patients, including the duration of visit and the reason that caused the E/M visit to take 30 minutes or more longer than average.

If your backup documentation is accurate, says Nelson, you have nothing to worry about. If were using a code we dont use normally, well think its going to red flag Medicare. If its a code that isnt used very often, someone on the payment side probably is going to look at it and ask if its legitimate. As long as youre documenting appropriately, thats OK.

And, says Nelson, its okay to be reviewed. Not all reviews are designed to make you look bad. Theyre to ensure that people are using the codes appropriately. Nelson says the only way the prolonged service codes will stop raising red flags is if people use them properly. The more you use the codes and the reviewers see that theyre being used appropriately, the more the payers, from a compliance standpoint, are going to see that these codes are working properly. Avoiding the codes is doing a disservice to those people who truly are using the prolonged services.

CPT 2000 states that prolonged service codes can be used only when the doctor spends at least 30 minutes more than the usual amount of time allowed for E/M services. The prolonged service codes are add-on codes, which means that they must be reported along with their corresponding CPT code to ensure payment. Section 15511.1 of the Medicare Carriers Manual (MCM), Part 3, outlines the appropriate add-on codes that correspond to the E/M codes. It also points out that the prolonged service codes are billable for direct face-to-face contact between the physician and the patient whether the service was continuous or not. Physicians should document all of the time they spend with the patient, even if they are coming in and out of the examining room at different times.

The MCM lists services that cannot be billed using prolonged service codes, including time spent by office staff with the patient or time the patient remains unaccompanied in the office. For prolonged hospital services, the MCM states, time spent waiting for test results, for changes in the patients condition, for end of a therapy or for use of facilities cannot be billed as prolonged services.