Pulmonology Coding Alert

Question: Can we report prolonged care services (CPT^® code 99354-99357) along with modifier 25, if the provider performed a significant and separately identifiable E/M service along with another separate procedure?

Alabama Subscriber

Answer: Yes, you may append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M service that is reported as the primary service. Prolonged care service codes, such as 99354 (Prolonged evaluation and management or psychotherapy service[s] [beyond the typical service time of the primary procedure] in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service]) are add-on codes which may only require modifier 25 if the payer prefers this mechanism of reporting, or if the prolonged care code is bundled into another service that can be appropriately unbundled with modifier 25. Verify that you can produce sufficient documentation that describes the service and justifies that the service was significant and separately identifiable from another service.