Wiki Prolonged E/M coding (medicare)

[helen]

How do I code (for Medicare) Treatment discussion plans (Pts that have been diagnosed with Breast Cancer) . Since Medicare does not pay consults anymore how can I code the Office visit established pt (99215) with over 40mins but not up over an hour more than 40 mns (99354)?

 

[Belinda Frisch]

Threshold

The time threshold for billing based on counseling/coordination of care for 99215 is 40 minutes. How long was the total visit? It is a little unclear from your message. The time to bill 99215 AND 99354 would be at least 30 minutes over 40 so 70 minutes minimum. CPT 99354 saus "first hour", but it really means first 30-74 minutes over the CPT threshold.

Make sure if billing based on time that total time, counseling time (reflecting >50% of total time) and content of counseling/care coordination is documented clearly in the medical record. Especially for Medicare.

How do I code (for Medicare) Treatment discussion plans (Pts that have been diagnosed with Breast Cancer) . Since Medicare does not pay consults anymore how can I code the Office visit established pt (99215) with over 40mins but not up over an hour more than 40 mns (99354)?

 

[helen]

Thank you so much for your quick response. My doc (gen surgeon) treats alot of Breast Cancer pts- therefore; he spends a great amount of time Counseling and coordinating benefits when diagnosed with cancer. In the case that the visit is 70 mins (min) I would code 99215 and 99354- would I use a modifier?
In the case that he only spent 60 mins total (and meets cc guidelines) would we be able to code any differently? Since Medicare does not except consult codes anymore, we are really struggling for solutions.

 

[sbicknell]

If these Treatment Discussion/Plan visits meet the guidelines for counseling and coordinating care, then code the entire visit based on time.

Meaning these 40 minute visits would code and bill as a 99215

Counseling and coordinating guideline: if more than 50% of the visit is spent counseling and coordinating (rather than eval and treatemnt), then code the encounter based on time rather than Hist/Exam/MDM.

Must document the total visit time. Must document how much of the time was specific to C&C. Must document "sufficient detail" to support time claimed.

For example, if the visit was 90 minutes and C&C guidelines are met. You would code 99215 (40 min) plus 99354 (prolonged care) for the remaining 50 minutes

No modifer is needed on the 99354 as it is an "add-on" code

The 99354 is for the first hour and you have to meet it 1/2 way (30 minutes) in order to code it in addition to 99215

So if total visit time is only 60 minutes and 40 of those minutes is applies to 99215 then that only leaves you 20 minutes which does not meet the 1/2 way mark. Code only 99215

If total visit time is only 70 minutes and 40 of those minutes is applied to 99215 then that leaves you 30 minutes and since it meets the 1/2 way mark you can code both 99215 and 99354