Pulmonology Coding Alert

Experts answer your prolonged services FAQs

Are you a little shaky on which in-office prolonged service codes to use when your pulmonologist spends extra time with patients?

If so, relax. Experts answer some common questions to help your prolonged service coding seem less daunting.

Q. When should we use prolonged service codes?

You should report prolonged care codes (99354-99355) only for your pulmonologist's face-to-face patient service "that is beyond the usual service in either the inpatient or outpatient setting," according to CPT. You shouldn't use prolonged care codes when nonphysician staff treat a patient. Also, you only report these codes in addition to other E/M codes that reference a specific time, such as established patient services (99211-99215).

Tip: Use prolonged service codes as add-on codes when an E/M visit exceeds the highest level of basic E/M service such as 99215. You should avoid using 99354-99355 for an E/M service less than a level four or five, says Antoinette Revel, CPC, a coding expert and nurse practitioner working at Healthcare Consulting Services in Warrington, Pa.

For example, a patient with a history of asthma (493.9x) presents with chronic obstructive asthma (493.2x) and moderate respiratory distress (518.82). During an initial evaluation, your pulmonologist finds wheezing (786.07) and difficulty breathing (518.82). Then your physician performs intermittent bronchial dilation (94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device) and injects subcutaneous epinephrine (J0170). Overall, your pulmonologist spends two hours in direct contact with the patient.

You should code your physician's E/M service as 99214 (Office or other outpatient visit ... for an established patient), which allots doctors 25 minutes to perform the service. In addition, you could assign +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient evaluation and management service]) for the first hour of your physician's prolonged service, and use +99355 (... each additional 30 minutes [list separately in addition to code for prolonged physician service]) for each additional 30 minutes. But you cannot bill for fragments such as five or 10 minutes.

Prior to using these codes, know how to calculate your physician's time - which may be harder than you think, says Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for RCH Healthcare Advisors LLC, a Fort Lauderdale, Fla.-based healthcare consulting company.

For instance, your physician spent 120 minutes with the patient, 25 of which you attribute to the office visit (99214), and 15 minutes to the bronchodilation (94640). This leaves your physician with 80 minutes of prolonged care. You should report 99354 for 60 minutes of care, which leaves you with 20 minutes. Because 99355 covers 30 minutes of treatment, you cannot bill for the leftover minutes, Revel says.
 
Q. Which E/M codes should we not report with 99354 and 99355?

Most Medicare and private carriers have strict guidelines for prolonged service usage. TrailBlazer Health Enterprises in Dallas, for instance, will not allow you to submit either 99354 or 99355 for established patient services of low complexity (99211), hospital observation (99217-99220), inpatient hospital care (99221-99223), subsequent hospital care (99231-99233), observation or inpatient care services (99234-99236), hospital discharge services (99238-99239), initial inpatient consultations (99251-99255), and follow-up inpatient consultations for established patients (99261-99263).

For example, your pulmonologist treats a patient with severe allergic reaction (995.3) with hives (708.0) and wheezing (786.07). Then the patient develops stridor (786.1) and has respiratory failure (518.81). Your physician spends two and a half hours with the patient. Because your physician provided critical care services, you should report 99291 x 1 (Critical care ...; first 30-74 minutes) for the first 60 minutes of service, and +99292 x 3 (... each additional 30 minutes [list separately in addition to code for primary service) for the additional 90 minutes of critical care, Revel says.

Not all insurers restrict prolonged care with 99354 and 99355, so you should check with your carrier for specific guidelines regarding which codes you can use with these codes.

Q. Can we use 99354 or 99355 if our pulmonologist exceeds the allotted E/M time by more than 30 minutes at different sittings?

Although CPT doesn't require that your physician perform prolonged service on a continuous basis, your physician should document all time spent with the patient. The medical record must document the duration and content of the E/M code to support billing prolonged services, according to the Medicare Carriers Manual (MCM). MCM, however, states that physicians don't have to submit documentation along with the claim for prolonged service codes. But you should have the documentation available in case a Medicare carrier targets your physician for medical review.

The documentation should include the start and stop times for the prolonged care, Revel says.

Q. Our pulmonologist met both requirements for using prolonged service codes and increasing the level of E/M service. Should we report the prolonged service or higher E/M code?

If your physician spent fewer than 30 additional minutes of direct contact with the patient, and counseling and care coordination still exceeded 50 percent of the E/M service's allotted time, you shouldn't use the prolonged service codes. Instead, report a higher-level E/M based on time. For example, if your physician spent 15 minutes on the E/M's key elements (history, exam, decision-making), and an additional 30 minutes counseling the patient, you should report 99215. Make sure your physician's documentation shows a visit of 45 minutes, 30 of which your physician spent counseling. Also, provide a brief summary of the topics your pulmonologist covered in the counseling, such as proper drug usage and treatment methods. That way you can show an auditor that your physician spent a reasonable amount of time counseling, Revel says.

On the other hand, if your physician performs a 40-minute office visit (99215) and then puts in another 60 minutes in face-to-face time with the patient, you can report prolonged service codes. In addition to 99215, you should assign 99354 x 1 (one hour and 40 minutes), Revel says.