Wiki Prolonged Services!!!

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smstgermain

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Hello everyone!!

I need some help with outpatient prolonged service, 99354. A Neuro psychiatrist that I do billing for uses this code frequently when he performs consultations (99205). Every insurance pays this except for BCBS RI, they first deny that code requesting documentation, I then mail in the medical record and they have been denying it stating his notes do not document time spent with patient. He codes for other services on seperate days and he includes that in one long note... (90801, 96118) and in his note he is switching back and forth from mental health to medical conditions. In the first paragraph of his medical records he states that he spent a total of 180 minutes with the patient but BCBS is not accepting that. Does anyone else have problems with documentation and prolonged services??? I read on-line where he should be documenting the time he begins and time he ends the visit in his note. I am very frustrated and so isn't he!!! I am trying to get in touch with a BCBS rep. but she isn't too reliable, so thought I would see if other billers/coders have any experience with this!! :confused:

Thanks!!!!
 
I've had a little experience with getting Anthem to pay for this 99354 Prolonged Service with Direct (face-to-face) patient contact, but it does take some time and perseverance and be prepared to follow the chain of instructions. It took us 10 months to get the last 99354 paid. I suspect part of the issue might be with the way that your physician documents his services in Anthem's eyes and may have to do with the time element in the 96118 in the "combo" type of chart notes, but is a guess on my part. You mentioned getting a hold of an Anthem rep....did you contact one from the Escalated services agents after normal customer service fails? Our neurology specialist is having some issues with another code, and we've had to enlist the support of escalated services. Unfortunately, they're not always quick to respond, so you may have to stay on their trail, email, call and log a good thread of documentation. It can be very frustrating....

I know this didn't directly answer your question, but at least let you know there are others out here who have and are experiencing similar issues. I'm hoping others more experienced with this type of coding scenario will respond.
---Suzanne E. Byrum CPC
 
smstgermain said:
Hello everyone!!

I need some help with outpatient prolonged service, 99354. A Neuro psychiatrist that I do billing for uses this code frequently when he performs consultations (99205). Every insurance pays this except for BCBS RI, they first deny that code requesting documentation, I then mail in the medical record and they have been denying it stating his notes do not document time spent with patient. He codes for other services on seperate days and he includes that in one long note... (90801, 96118) and in his note he is switching back and forth from mental health to medical conditions. In the first paragraph of his medical records he states that he spent a total of 180 minutes with the patient but BCBS is not accepting that. Does anyone else have problems with documentation and prolonged services??? I read on-line where he should be documenting the time he begins and time he ends the visit in his note. I am very frustrated and so isn't he!!! I am trying to get in touch with a BCBS rep. but she isn't too reliable, so thought I would see if other billers/coders have any experience with this!! :confused:

Thanks!!!!
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I am confused by your scenario. Are you saying that he combines time spent for several days and then wants to bill prolonged time? If you can give me a better picture I can assist I think. Prolonged time cannot be appended to 90801 or 96118 and it cannot be cumulative form different encounters. It is documentation of time spent in a single encounter for office levels or the 90809, that exceeds the time for that level by a minimum of 30 minutes.
 
prolonged

In the incidents when I was able to get prolonged service paid, the documentation was very specific about how much time was spent in prolonged service, the reason why it couldn't be covered in normal time and what specifically was covered in that time.
 
He splits these codes into two different days.... he codes for the office consult and prolonges service on one day...then the next appointment he see's the patient he will code for the 90801 and 96118, however these four codes are included in one long medical note....his only documentation of time is in his opening paragraph where he states he spent a total of 180 minutes with the patient.
Thank you for reading my post and for trying to help me!!
 
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