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Pain Management Coding Alert

Reader Question:

Dodge High-Level Prolonged Services Myth

Question: Can you report prolonged services with any level of evaluation and management (E/M) code, or just the highest-level E/M codes? My colleague and I are debating this topic.

Washington, DC Subscriber

Answer: It's a common myth that prolonged care services can only be reported with the highest level of E/M code, like 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity ...) or 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity ...) for office services. However, this is not true.

You can report prolonged care codes +99354 (Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service)) and +99355 (...each additional 30 minutes (List separately in addition to code for prolonged service)) with any level of E/M code. However, the documentation must support the reason why and give the details of the service.

To report a prolonged care services code like +99354, your clinician should have performed the E/M service beyond the typical time stipulated in the descriptor for that particular E/M code.

For example, a 99203 (... a detailed history; a detailed examination; medical decision making of low complexity ...) service typically takes about 30 minutes. When the session extends beyond this time, you can claim reimbursement for the additional time by reporting +99354 and +99355, as appropriate, according to the time spent. The details of the note should then indicate why the extra time was necessary. This is different than counseling and coordinating care too. When that occurs, the note should indicate the counseling or coordination of care along with the total time of the visit and the indication that more than half of that time was spent in that activity. The prolonged codes are used when the actual E/M service is extended.