These codes can only be reported when the prolonged service is provided face-to-face with the patient, and may be reported in the inpatient or outpatient setting, she says. These service codes are based on time spent with the patient, so a prolonged service time of less than 30 minutes would not be reported separately.
To document accurately the prolonged service for appropriate reimbursement, the physician should make a separate entry in the medical record, Mulholland advises.
Documentation for this service must include:
A description of the visit content
The amount of extra time spent with the patient
Total time of the visit.
The provider should report the E/M service, for example, 99213 (established patient with two of three key components and low to moderate severity of presenting problem with 15 minutes typically spent face-to-face with the patient), and the prolonged service code (99354).