Urology Coding Alert

1 rule when reporting add-on codes will make - or break - your claims

Urology coders understand that the E/M codes contain a time allotment for performing the service. But what do you do when the urologist goes over that allotted time?

Prolonged service codes (99354-99357) may hold the key to boosting your pay when your urologist spends more than the usual face-to-face time allotted for E/M services.

Here is a closer look at the prolonged service codes, when to use them, and what your prolonged service claim should look like before sending it to the carrier.

Report 99354-99357 When Crossing Threshold Time

A urologist performs a level-two E/M service on an established patient that takes 50 minutes.

Example: An established patient comes for a routine follow-up for BPH worsening on medication. The E/M level is limited to 99213 because the urologist documents only a pertinent review of systems as part of the patient's history. The urologist ends up spending more time with the patient than the 15 minutes that 99213 specifies.

In this case, you should report a prolonged service code with the E/M code on this claim.

The claim should read:

99213 - Office or other outpatient visit for the evaluation and management of an established patient ...

+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).

Tip: Use 99354 for the first 30-74 minutes of outpatient prolonged service time and +99355 (... each additional 30 minutes [list separately in addition to code for prolonged physician service]) for each additional half-hour for outpatients beyond 74 minutes.

Remember: To use the first-hour prolonged service codes, the urologist must have provided at least 30 minutes of service time beyond the CPT Codes -allotted "threshold time" for that E/M service, coding experts say. Also note that prolonged service codes are add-on codes, so you should never report prolonged service codes alone, coding experts say. And you do not need to add a modifier to an add-on code when you report it with an E/M code.

Bottom line: The prolonged service time must be face-to-face time between the physician and patient. If you haven't met that requirement, the prolonged service codes are not applicable.

Important: In order to report the E/M code on time alone, without prolonged care, the physician must spend more than 50 percent of the total visit time (spent between the patient and physician face-to-face) counseling and coordinating care for that patient.

Exception: You do not need to follow this rule when you report an extended visit sing prolonged care codes to indicate the extra work expended.

Total Time Includes Time Spent on Explanation

If your urologist spends a great deal of time talking to the patient or the patient's family about a complex issue, however, you should also consider that time as part of your prolonged service.

Example: A urologist treats a 79-year-old male who is an established patient in the office for a suspicious growth on the urethral meatus. During the examination, the urologist decides that he should remove this growth with a biopsy.
 
The patient has several questions about his condition and the surgical service. The urologist discusses these issues in detail. Also, the patient's daughter, who is in town with her children visiting for spring break, is also present at the time of service.
 
The total time spent for this visit is 100 minutes, and the urologist spends a total of 60 minutes counseling the patient and his daughter on his condition and plan of treatment.

Coding solution: In this case, you should report 99215 (Office or other outpatient visit for the E/M of an established patient ... physicians typically spend 40 minutes face-to-face with the patient and/or family), because the first 40 minutes, including the history and physical examination and the initial discussion, would be the determining factor in code selection. Report the remaining 60 minutes with 99354.

Time Can Pay, But Beware This Hitch

If the urologist spends more than 50 percent of the face-to-face time counseling and coordinating care, you can report an E/M service based on time alone, says Lisa Center, CPC, independent coder in Joplin, Mo.

Example: If the urologist's notes indicate that he performed a level-four established patient E/M service in the office that took 80 minutes, and he spent 45 of those minutes counseling the patient, you would choose the E/M level according to the time requirements and not the three key components (history, exam, medical decision-making), says Tina Miller, CPC, coder and biller for Urology Associates of Central California in Fresno.
 
Report the level-five E/M code (99215) and a prolonged service code (99354), Miller says.

Include specific documentation on the 45 minutes of counseling to strengthen your claim. Because you are reporting two codes, the notes from the urologist should clearly explain two services.
 
Documentation tip: To ensure clear sailing through any questions regarding the use of both codes, have the urologist dictate or write separate notes for each code you report. Your urologist can document these notes on the same page of the medical record with appropriate headings and paragraphs.