Radiology Coding Alert

Question: Our interventional radiologist saw a patient during an E/M service for a prolonged amount of time. Can I bill +99354 with 99214?

Oregon Subscriber

Answer: If you are considering the use of prolonged evaluation and management (E/M) services code +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)), you need to know that you may submit 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; ...) so long as you reach 99214 using the 1995/1997 E/M guidelines.

However, if you’re reporting based on a time estimation, you may only do so when you’ve reached 99215. That’s because, as the Centers for Medicare & Medicaid Services (CMS) explains in MLN Matters #MM5972, “in E&M services in which the code level is selected based on time, you may only report prolonged services with the highest code level in that family of codes as the companion code.”

This means that if the time of the established patient visit only allows you to reach 99214, then you may not report a prolonged services code in addition to the E/M code. However, if you use history, exam, and medical decision making (MDM) to determine the E/M visit, you may report any code within code range 99212-99215.

So, if you are thinking of reporting of a prolonged services E/M code in addition to your time-based established patient visit, you first need to make sure you’ve got the documentation to reach code 99215 (…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 comprehensive hist ...).

In order to reach 99215 using time-based rules for E/M reporting, the physician would have to document greater than 50 percent of the visit performing counseling/coordination of care services. This means that the physician must document more than 20 minutes providing counseling/coordination of care services for an E/M visit that exceeds 40 total minutes. This is based on the “typical” 40-minute time estimation for 99215 outlined in the CPT^® manual. This time estimation is important in determining the prolonged services code. While you may reach 99215 using the three key components, you cannot begin to document the time for a prolonged services code before the 40-minute timeframe has been reached.