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 [...]