Pulmonology Coding Alert

You'll have to count hospital time differently for Medicare beneficiaries.

An expansion of the 99356-99357 codes means physicians can bill for more of the prolonged care they provide to inpatients, provided you educate them on these requirements.

Doctors now can bill for unit/floor time for such activities as reviewing medical records, documenting, and discussing the case with other involved providers on the floor and at the nurses' station, explains Carol Pohlig, BSN, RN, CPC, ACS, senior education and coding specialist with the University of Pennsylvania Department of Medicine in Philadelphia.

The revised codes you don't want to miss billing for are:

•99356 -- Prolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual services; first hour (List separately in addition to code for inpatient Evaluation and Management service)

•99357 -- ... each additional 30 minutes (List separately in addition to code for prolonged physician service).

If the doctor does not meet the E/M service threshold, plus an additional half hour of time, you should not report 99356, says Pohlig. The doctor cannot provide any other services to any other patients during the time that he is billing for 99356 and 99357. For questions about Medicare's threshold requirements, see the Medicare Claims Processing Manual (MCPM), Chapter 12, Section 30.6.15.

Catch: The face-to-face requirement is still in effect for prolonged outpatient care (99354, Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management service]; and 99355, ... each additional 30 minutes of prolonged patient care [List separately in addition to code for prolonged physician service]), says Anne Holmes, RN, BSN, CPC, senior coding and education specialist in the University of Pennsylvania Department of Medicine.

Count only the billing provider's time counts. You cannot bill for residents or fellows who spend time on the patient, Pohlig points out. And you cannot split the time between two physician bills -- you must report the cumulative time under one physician's name.

Example: If physician A provides the base E/M service (99232) in the morning and physician B meets the prolonged care criteria (99356) in the afternoon, you must report both codes under one physician's name, as long as they are in the same group and specialty, notes Pohlig. If the two doctors are not in the same group or are in the same group but different specialties, they would each bill separately for their services, such as 99232 and +99356 as appropriate after each meets the threshold individually, she says.

Medicare has not accepted the change in the face-to-face requirement. CMS guidelines pay for only direct physician-patient time, not indirect services, such as reviewing charts, discussing a patient with house medical staff, or waiting for test results (MCPM, Chapter 12, Section 30.6.15.1C). The physician will have to indicate how much time he spends on direct services, as well as how much time he spends on indirect services that you will not count towards 99356-99357.

You should never use 99356 alone. It is reported as an add-on code typically with a subsequent hospital care code (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...). Prolonged inpatient care may also be reported with initial hospital care (99221-99223), inpatient consultations (99251-99255), and nursing facility care (99304-99318).

Code 99357, as indicated in its descriptor, is also an add-on code. You must use it with both an E/M code and 99356.