Pulmonology Coding Alert

Question: A 40 year old gentleman, a known asthmatic, came in with respiratory distress and bronchospasm. Assessment findings revealed a high respiratory rate (26 per minute), wheezing, and use of accessory muscles in breathing. The provider gave him 2 inhalation treatments, and administered epinephrine subcutaneously. The treatment process took over two and a half hours to stabilize the patient, and get the respiratory vitals back to normal. How do we claim for the extended time of service that was given to the patient?

Utah Subscriber

Answer: In this case, to begin with, let us assume the total service time was 130 minutes, as documented by the provider, taking into account the intermittent nature of the service. It does not matter if the provider rendered the services intermittently, so long as the total time of service is documented well. In order to report prolonged time, the provider must meet the minimum threshold time for the E/M being reported.

Here, use the E/M service code 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity… Typically, 25 minutes are spent face-to-face with the patient and/or family).

As the reference time or 99214 is 25 minutes, you will need to exclude the time it takes to administer the nebulizer treatments and epinephrine (since these are being billed separately). If these combined procedures took 35 minutes, there is 70 minutes of time remaining. This would only allow for the use of prolonged service code 99354 since the threshold time was not met in order to bill the additional code, 99349. However, if the physician did not spend this additional 70 minutes face-to-face with the patient, he/she cannot bill prolonged care. It comprises direct patient care by the billing provider rather than how much time the patient spent in your practice or with other staff members.