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tsmaldone

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Does anyone have any documentation regarding the prolonged codes and how often you can use it in one day. CPT states, "..should be used on once per date.....". I was always taught that once per day was it and that it did not say once per day per patient. Please let me know what you thing and if there is documentation on this anywhere.
Thanks,
Teri
 
tsmaldone said:
Does anyone have any documentation regarding the prolonged codes and how often you can use it in one day. CPT states, "..should be used on once per date.....". I was always taught that once per day was it and that it did not say once per day per patient. Please let me know what you thing and if there is documentation on this anywhere.
Thanks,
Teri
Click to expand...

Per the instructions prior to the codes, these are once per day per patient. For example: "Codes 99356-99357 are used to report the total duration of unit time spent by a physician on a given date providing prolonged service to a patient, even if the time spent by the physician on that date is not continuous." You do not add together all the extra time the physician spent with all the patients and bill it under just one patient; rather, you bill a patient's insurance only for the prolonged services for that patient (if there were any).

Hope this helps. I see this is posted under multiple topics.
 
Lord help me

In the CPT book under all of the Critical care codes it states "..per date, per patient.." The CPT code for prolonged services should read per date per patient and doesn't. I never thought about adding them up at the end of the day. If you use too many prolonged service codes per day a red flag is going to go up. I seem to remember that the prolonged code used to be used only on the highest level code per section. The logic was that adding a prolonged code on to a lower level would, if the documentation supported it, lead you to the next highest code. My memory may be on the decline so I may be uttering nonscence, but I still have a tiny alarm in my head going off about this. Is there any concrete evidence regarding how many times you can use this code in one day? It doesn't say per patient. The amount of time attached to E/M's is an estimate, we all agree on that right? What if in the specialty of Neurology the average time is 1 hour for the lowest level, you are then limited to 7 to 8 patient's a day and if they all required prolonged service you could possibly be at work for 13 to 15 hours per day. Everyone is agreeing with you and I probably should as well but again that little alarm is going off.
 
tsmaldone said:
In the CPT book under all of the Critical care codes it states "..per date, per patient.." The CPT code for prolonged services should read per date per patient and doesn't. I never thought about adding them up at the end of the day. If you use too many prolonged service codes per day a red flag is going to go up. I seem to remember that the prolonged code used to be used only on the highest level code per section. The logic was that adding a prolonged code on to a lower level would, if the documentation supported it, lead you to the next highest code. My memory may be on the decline so I may be uttering nonscence, but I still have a tiny alarm in my head going off about this. Is there any concrete evidence regarding how many times you can use this code in one day? It doesn't say per patient. The amount of time attached to E/M's is an estimate, we all agree on that right? What if in the specialty of Neurology the average time is 1 hour for the lowest level, you are then limited to 7 to 8 patient's a day and if they all required prolonged service you could possibly be at work for 13 to 15 hours per day. Everyone is agreeing with you and I probably should as well but again that little alarm is going off.
Click to expand...

Of course, if your physician is billing prolonged services for 10 patients in one 8 hour period, you would have cause for alarm - but are they charging prolonged services for every single patient and documenting the time? But again, per the instructions prior to the codes, these are per patient; they are in addition to a companion E/M service - so how could you combine patients? Here is a link to a Part B article about prolonged services from my carrier, Noridian. It is from MLN Matters # MM5972, so applies to all CMS, not just Noridian. Hopefully this will help: http://bbnor.noridian.com/Bulletins...ged_Services_-_Codes_99354_through_99359_.htm
 
You must think I am incredibly stuborn and possibly annoying but I have a problem. If I use the threshold times like it stated in the bulletin, almost every single one of our visit will be prolonged. The shortest visit time, face- to-face is 45 min for a 99212. A new patient could be 2.5 hours. Diseases like parkinson's and alheimer's effect the entire body, every system. Am I suppose to revamp the threshold times to fit our specialty?
Bulletin states
99212=10 minutes plus the additional 30 making threshold 40 minutes
Our services
99212=45 minutes plus the additional 30 would result in a threshold time of 75 minutes
Does this seem fair?
I appreciated you for helping me with this. It did mention in the bulletin that these codes used to be added on only to the highest level in a given category I new I had that right in my head. It's different now it can be any category.
 
Let me see if I can help clarify.... prolonged time codes can be added to any level of service withing a given category, if you look at the codes in the book you will see the codes the 99354 and 99356 can be added to. If you have the documentation to support a 99212 and your physician documents a total of 45 minutes spent with the patient then you have exceeded the threshold and you can bill a 99212 with a 99354. Ok so let me teach it the way I do in class. using your example of a bona fide 99212 (because you cannot downcode) As long as the physician documentes the total time spent, and it is better if this is time in and time out fashion, and you have the 45 stated minutes. OK?
so take the total time 45 and subtract the visit level time wich is in the CPT book as 10 minutes, and what you have left is 35 minutes..... it takes a minimum of 30 minutes to after the subtraction to be able to use the 99354.
Put it another way....
99354 and 99355 are 1hour codes, you must a minimum of half the required time to be able to bill a timed code. so once you subtract out the visit level time which is what is assigned in the CPT book per code then you need a minimum of 30 minutes so the chart you are looking at for threshold times says for a 99212 40 minutes, that is the 10 minutes for the 99212 plus the minimum of 30 minutes for the 99354.
so a 99354 goes from 30-60 minutes... now the 99355 is for the additional 30 minutes and you must have an addition of a minimum of 15 minutes above the 99354 to bill this code soooooo once you reach the 75 minutes over the visit level (the 60 plus the 15) then you can add the 99354 plus the 99355. So you will see the threshold for the 99355 with a 99212 is 85 minutes, 10 minutes for the 99212 plus 75 for the 99354 plus 99355.
I hope this has been helpful for you.
 
Prolonged care care be very confusing but go to this CMS link and read the description of what qualifies for prolonged care - it also has examples of billable and non billable prolonged care.

http://www.cms.gov/manuals/downloads/clm104c12.pdf

You can have a level 2 (10 minutes) plus and additional 30 minutes (total of 40 minutes) as long as time is documented for both the base code and the additional time spent and it exceeds the threshold time you can report both the base code and prolonged care.

Now, the caveat to this is when the E/M service is based on greater than 50% of the encounter in counseling/coordination of care. CMS specifically states that the time for highest level code in a given category must be met PLUS the additional minimum 30 mintues face to face time in order to report prolonged care. So in this sceanrio you would have to meet 75 minutes and report a 99215 + prolonged care code.

IN the situation you described, if greater than 50% of the time is spent in counseling/coordination of care and a total of 45 minutes was spent you would report a 99215 only.

This is specific to Medicare but many payers follow Medicare guidelines. You can query your largest payers or check websites to find out if they have different prolonged care policies.

As was stated in a previous answer - there is only 24 hours in a day - Keep this in mind when 20 patients were seen in one day by one provider and prolonged care is reported on every one of them!


Here is an excerpt from CMS Pub 100-04 Chapter 12 -

H. Prolonged Services Associated With Evaluation and Management Services Based on Counseling and/or Coordination of Care (Time-Based)
When an evaluation and management service is dominated by counseling and/or coordination of care (the counseling and/or coordination of care represents more than 50% of the total time with the patient) in a face-to-face encounter between the physician or qualified NPP and the patient in the office/clinic or the floor time (in the scenario of an inpatient service), then the evaluation and management code is selected based on the typical/average time associated with the code levels. The time approximation must meet or exceed the specific CPT code billed (determined by the typical/average time associated with the evaluation and management code) and should not be “rounded” to the next higher level.
In those evaluation and management services in which the code level is selected based on time, prolonged services may only be reported with the highest code level in that family of codes as the companion code.


Hope this helps :eek:
 
Thanks

Thank you sooo much. I got confused but thanks to all of you I have found my way back into the light. It's all good now.
Thanks again
Teri
 
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