Wiki Prolonged Care 99417

[cbo014]

Can any one help me with this code? I have a PAC that charges it with every 99215 and 99205 she sees. I don't see the medical necessity but I'm getting tired of arguing about it. She typically documents a 99215 and a 99417, 45 minutes face to face, 10 minutes documenting and 5 minutes faxing or 60 minutes face to face, 15 minutes documenting and reviewing meds. My thoughts are that Documenting and reviewing meds should be part of the E/M and we have staff that can fax. I feel like she uses this code to fill in time gaps to meet the 99215/99205. Any help is appreciated. Thanks

 

[kdlberg]

Use of 99205/99215 should be rare in most office settings, because in general, the presenting problems and management options are not going to be high risk. If she is going to code based on time, she needs more specific documentation: what did she do to prepare to see the patient? Did she review prior records and what did she find (or if nothing was found, state that)? How much time was spent ordering tests, prescriptions, etc.? Did she discuss the patient with an external provider?

It all boils down to she needs to show her thinking process so an auditor can see why the visit took excess time. Remind her that most auditors are not clinicians and while we understand what something is, we might not know what it means. How serious is this diagnosis, and how serious is it for the patient?

 

[sls314]

Use of 99205/99215 should be rare in most office settings, because in general, the presenting problems and management options are not going to be high risk. If she is going to code based on time, she needs more specific documentation: what did she do to prepare to see the patient? Did she review prior records and what did she find (or if nothing was found, state that)? How much time was spent ordering tests, prescriptions, etc.? Did she discuss the patient with an external provider?

It all boils down to she needs to show her thinking process so an auditor can see why the visit took excess time. Remind her that most auditors are not clinicians and while we understand what something is, we might not know what it means. How serious is this diagnosis, and how serious is it for the patient?

Also, if every single Level 5 visit she bills manages to be exactly 60 minutes, that will probably be a red flag for an auditor, too.

 

[cbo014]

Is her documentation of just 60 minutes even enough? I thought for a 99215 she had to have at least 55 min and 99205 75 min, she's using the prolonged to make the full 60 minute appt. I don't think that is right.

 

[sls314]

Is her documentation of just 60 minutes even enough? I thought for a 99215 she had to have at least 55 min and 99205 75 min, she's using the prolonged to make the full 60 minute appt. I don't think that is right.99215 requires 40 minutes to report by time. When the time meets or exceeds 55 minutes, 99417 can be reported.

60 minutes would be enough to report prolonged services 99417 for an established patient, but not a new patient.

99215 requires 40 minutes to report by time. When the time meets or exceeds 55 minutes, 99417 can be reported.
99205 requires 60 minutes to report by time. When the time meets or exceeds 75 minutes, 99417 can be reported.

 

[cbo014]

60 minutes would be enough to report prolonged services 99417 for an established patient, but not a new patient.

99215 requires 40 minutes to report by time. When the time meets or exceeds 55 minutes, 99417 can be reported.
99205 requires 60 minutes to report by time. When the time meets or exceeds 75 minutes, 99417 can be reported.

Thank you. I thought that she had to have 55 minutes before she could use the 99417. I still don't think she is using it correctly. She puts it on every 215 and 205 that she sees because somebody told her that she could. They obviously didn't explain that there has to be a medically necessary reason. She is a mental health provider, so I feel that this would be used on rare occasions. Most of the documentation that I have read is simply a follow up or medication management. They bill every visit time based.

 

[sls314]

Thank you. I thought that she had to have 55 minutes before she could use the 99417. I still don't think she is using it correctly. She puts it on every 215 and 205 that she sees because somebody told her that she could. They obviously didn't explain that there has to be a medically necessary reason. She is a mental health provider, so I feel that this would be used on rare occasions. Most of the documentation that I have read is simply a follow up or medication management. They bill every visit time based.

Oh, I absolutely agree that something isn't right with the way she's using it! As I mentioned in a different reply above, it would also be a red flag to an auditor if every visit is exactly 60 minutes. They'd definitely dig a little deeper upon seeing that.

I was just clarifying the time thresholds for when it is being used appropriately.

I can't find it quickly now, but when I get a chance I'll try to pull reference about prolonged services. It might be helpful for her to see from an official, reputable source.

 

[Jamitch1984]

I code in special radiation therapy for cancer and code for 4 providers. They rarely document enough time to bill this code, but some times in very complex patients they will.