Wiki 99356 Prolonged services. What documentation is required to get this service paid.

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Kathy Perry

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We want to charge for a prolonged Subsequent In-Patient visit that lasts longer than 45 minutes total time for 1 day.
would 99233 subsequent care & 99356
What exactly needs to be documented?
Also does the start & stop time need to be documented or just an average of total time spent with a narative of what was done during that time documented.

Lost,
kperry
 
You do not need to document start and stop times.

To bill 99233 and 99356 total time documented must be between 65 and 104 minutes. This time must be direct face to face contact between the patient and the physician. It does not need to be continuous.
 
The CPT book has good information on this. For the E&M code you need to spend at least the time specified in the E&M code (99233 is 35 min) plus a minimum of an additional 30 min of face to face time (doesn't need to be continuous) to add on 99356. So as stated above 65-108 min (35+74 min per the chart in the CPT book) total for those 2 codes to be billed together.
 
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