Pulmonology Coding Alert

Tip: Use 99354 for the first 30-74 minutes of outpatient prolonged service time and +99355 (... each additional 30 minutes [list separately in addition to code for prolonged physician service]) for each additional half-hour for outpatients beyond 74 minutes.

Exception: If, however, your pulmonologist provides prolonged service in an inpatient setting, you should refer to the following different prolonged service codes:

Remember: To use the first-hour prolonged service codes, you must provide at least 30 minutes of prolonged service time beyond the CPT-allotted time for that E/M service, coding experts say.

The prolonged service time must be face-to-face time between the physician and patient.

Bottom line: If you haven't met that requirement, the prolonged service codes are not applicable.

In general, you should not upcode the level of E/M service based on time; only raise the level of E/M service if the pulmonologist provides a higher level of service.

To report the E/M code on time, without prolonged care, the physician must spend more than 50 percent of the total visit time (spent between the patient and physician) counseling and/or coordinating care.
 
Exception: You do not need to follow this rule when you report a visit level with prolonged care.

Total Time May Include More Than You Think

When your pulmonologist spends a lot of time talking to the patient and/or the patient's family about a complex issue, you should also consider that time as part of your prolonged service.

Example: A pulmonologist treats a 69-year-old male who is an established patient in the office for a primary pulmonary neoplasm. During the course of the examination, the pulmonologist decides that this growth is operable using partial lobectomy.

The patient has several questions about his condition and the surgical service. The pulmonologist discusses these issues in detail. Also, the patient's daughter, who is in town visiting for spring break, is also present at the time of service.

The total time spent for this visit is 100 minutes, and the pulmonologist spends a total of 60 minutes counseling the patient and his daughter on his condition and plan of treatment.

Coding solution: In this case, you should report code 99215 (Office or other outpatient visit for the E/M of an established patient ... physicians typically spend 40 minutes face-to-face with the patient and/or family), because the first 40 minutes of the examination would be the determining factor in code selection

You would report the remaining 60 minutes using prolonged service codes (99354-99359). The most important thing to remember when coding for prolonged services when face-to-face contact does occur is that there are two different codes for two different places of service.

Red flag: Codes 99354 and 99355 are for any office or outpatient service, and 99356 and 99357 are for inpatient settings. In the example above, you should code the additional 60 minutes of face-to-face time with 99354 because this code is for 30-74 additional minutes of face-to-face time, Nugent says.

Exception: However, if the pulmonologist spends more than 50 percent of the face-to-face time counseling and coordinating care, you can report the E/M service based on time, says Lisa Center, CPC, an independent coder in Joplin, Mo.

For example, if the pulmonologist's notes indicate that he performed a level-four established patient E/M service in the office that took 80 minutes, and he spent 45 of those minutes counseling the patient, you would choose the E/M level according to the time requirements and not the three key components (history, exam, medical decision-making) and report the level-four E/M code (99214) and a prolonged service code (99354). Include specific documentation on the 45 minutes of counseling to strengthen your claim.