Wiki prolonged service HELP PLEASE

[nadethb]

I need clarification on how to interpret the medicare internet only manual for prolonged services.
if the provider has documented that he spent 35 minutes with the patient for initial visit in which 20 minutes (of the 35)was spent on direct face to face counseling the patient he billed 99233 based on time, above the basic service the provider documents and additional 30 minutes of prolonged service billing 99356. the medicare only manual seems to suggest that if the provider would have spend the full 35 minutes of the initial visit counseling the patient PLUS 30 extra counseling, then he could bill the prolonged services? Please clarify this, Medicare keeps denying that prolonged service stating it did not meet the threshold for direct face to face time.
Thank You

 

[mitchellde]

If the provider spent a total of 35 minutes then you will not have prolonged time criteria met. The threshold time for the prolonged time codes is the visit time plus a minimum of 30 minutes then you bill that level plus the 99354.
So say a 45 minute encounter. The provider documentation supports a 99213. 99213 is 15 minutes 45-15 =30 minutes so you can append the 99354. If the documentation supports a 99214 that is 25 minutes 45-25=20 minutes which is not enough for prolonged time so the visit stays as a 99214.

 

[nadethb]

thank you for the reply, but I was looking for a more specific answer to the inpatient example I have stated above

 

[espressoguy]

I have a couple of thoughts on why this may have been denied, but without seeing the provider's time statement they would just be guesses.

1. Can you post the provider's time statement
2. Has this been appealed with notes.
3. Without time based coding does the encounter equal a 99233.

 

[mitchellde]

I have a couple of thoughts on why this may have been denied, but without seeing the provider's time statement they would just be guesses.

1. Can you post the provider's time statement
2. Has this been appealed with notes.
3. Without time based coding does the encounter equal a 99233.

Apologies as my response was meant to be just generic.. For your scenario the provider must meet the criteria for the 99233 from the basis of the three key components. A 99233 is a 35 minute encounter on average to complete the components. To bill prolonged time the provider would need to document a total of 65 minutes spent with the patient at a minimum. If the three key components do not meet a 99233 then you bill the level of care met say a 99231, which is 15 minutes then if the provider spent 65 minutes total you would bill the 99231 and then the 99356. So it is entirely possible that the payer feels the visit level itself is not a 99233 but needs to be a lower level given the documentation of the three key components.

 

[nadethb]

I have a couple of thoughts on why this may have been denied, but without seeing the provider's time statement they would just be guesses.

1. Can you post the provider's time statement
2. Has this been appealed with notes.
3. Without time based coding does the encounter equal a 99233.

Yes, this has been appealed with notes and denied.
99233 was billed based on time coding.
Here is the provider time billing statement:
"For initial hospital visit I spent 35 minutes with the patient in direct floor time and 20 minutes of that time was spent in face to face discussion with the pt and her family about her prolonged hospital stay and complicated diagnosis. Above this basic service. I spent and additional 40 minutes between the hours of 1030 and 1230 with the pt and her family in prolonged face to face service, in further discussion about discharge planning, prognosis, benefits and burdens of SAR stay vs. home with hospice support."

thank you

 

[mitchellde]

Sounds like it should be a 99231 with the 99354.you cannot base the visit on time and then add time on top. You base the visit on the three key components and the subtract that from total time.