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Blackhorse Posted Tue 02nd of January, 2018 17:04:23 PM
Reason for visit: CERVICAL/THORACIC/LUMBAR SPINE--NEW PROBLEM HPI A lady comes in for evaluation of her neck, mid and low back throughout plane crash. She was last seen in April 2016 after motor vehicle accident. I recommended physical therapy as she was improving on her second visit. The plan was to have her follow-up as needed. Then, unfortunately 5 days ago, she was involved in a plane crash in ABC Valley. The patient states she has 80% neck and back pain and 20% extremity discomfort. Her symptoms range from 3-9 out of 10 in severity. It is aching exhausting tender throbbing pain which affects wakes her up from sleep, and keeps her from falling asleep. It is worse with standing and sitting reaching getting out of bed lying face down twisting bending coughing going up and down stairs and pulling and pushing. It is made better by Tylenol pain medication. She has also taken some ibuprofen. Both have been somewhat helpful. She has not done any therapy. She is here for evaluation. The patient states that she was up and a single injection plane and the engine lost power. She was a passenger in a made a crash landed striking a tree and flipping over. She was taken to ABC County Hospital. She had multiple studies including CT scans of her cervical spine along with MRI of the cervical spine. She also had x-rays of her thoracic and lumbar spine. The patient also had multiple x-rays. She was diagnosed with a left proximal humerus greater tuberosity fracture. She was told not to weight-bear initially first on one leg than the other but the reason was unclear. She was told it was because of a possible lumbar spine Diagnostic Studies 5 views of cervical spine including AP, lateral, odontoid, flexion, and extension views obtained in the office today show straightening of cervical lordosis. 2 views of thoracic spine including AP and lateral views obtained in the office today show no obvious bony abnormality 5 views of lumbar spine including AP, lateral, cone down, flexion, and extension views obtained in the office today show straightening of lumbar lordosis. A CT scan of the cervical spine showed no clear-cut obvious fracture but there was what appeared to be a nutrient vessel versus a very minor occult fracture of the anterior and posterior ring of Cl. Compression fractures reported in the upper thoracic levels T1-T2 and T3 but these were difficult to assess definitively. I obtained an AP pelvis and inlet and outlet views of the pelvis along with 45° oblique views. These are also known as Judet views. 4 views of a left shoulder including AP, scapular-Y, axillary lateral, and internally rotated AP views obtained in the office today show a minimally displaced greater tuberosity fracture with a millimeter or 2 of displacement. Impression Left proximal humerus greater tuberosity fracture Suspected ring of Cl fracture Suspected Tl, T2, T3 compression fractures Possible occult lumbar compression fracture Multiple contusions Plan/Recommendation I recommend the patient maintain her cervical collar. I recommended weightbearing as tolerated. I recommended MRIs of the cervical thoracic and lumbar spine to further evaluate for occult injury. I will have her maintain her collar in the interim. recommended judicious use of medications. Regarding her left shoulder, I would recommend use of the sling for her greater tuberosity fracture. Twill start Codmanis activities in a week or so and gradually to passive range of motion a month after the injury going to active range of motion at 2 months post injury. Strengthening will start at 10-12 weeks after the injury for her left shoulder. I will await the results of the cervical thoracic and lumbar MRI before making further recommendations regarding her spine. I recommend a back brace. I'll provide the patient with a back brace to provide anterior, posterior and lateral support and help reduce pain by restricting motion through the trunk and lumbosacral region. One was fitted to and provided for the patient with detailed usage instructions. All questions were answered. Please note a significant amount of time was spent for record review going over the multiple imaging studies as well as the extensive paperwork. A total of 1 hour and 20 minutes of direct patient record and image review along with patient's evaluation and discussion resulted. I will give her some tizanidine for spasm. Multiple imaging studies were reviewed as detailed above. DOCTOR WANTS TO CHARGE EXTRA FOR THE TIME HE SPENT FOR REVIEWING PATIENT'S RECORD,IMAGE AND OTHER EXTENSIVE PAPERWORK. CAN HE BILL 99358 AND 99215? THE INSURANCE IS ANTHEM. Or 99354 is more appropriate.
SuperCoder Answered Wed 03rd of January, 2018 06:16:53 AM


You can bill an E/M code that has a time component (such as 99201-99215, Office or other outpatient visit along with 99354…To bill a prolonged service you must have documentation for a prolonged service that is more than 30 minutes beyond the typical time listed for the code you billed and have the medical need clearly stated for the prolonged service. 

99215=40 minutes, for remaining 40 minutes you can bill 99354.

99358 is for non face to face visit:-

1. CPT Codes 99358 and 99359 may only be used when a prolonged non-face-to-face service Is neither:
           i. Face-to-face time with a patient during an evaluation and management service in the office or outpatient (non-facility) setting, nor
           ii. Additional time in a facility setting during the same evaluation and management service¹


       b. Is “beyond the usual” time a provider would spend on a service.

  2. Prolonged service is to be reported in relation to other physician or other qualified health care professional services, including evaluation and management services at any level. 

  3. A provider is allowed to bill for non-face-to-face prolonged service on a different date than the primary service.

  4. However, prolonged service must relate to:
       a. The past or future direct, face-to-face care of the patient
       b. Ongoing patient management


Hope that helps!


Blackhorse Posted Thu 29th of March, 2018 14:53:29 PM
We have received denial for 99354 from Blue Cross. It states "In accordance with the Health Plan's Prolonged Services Reimbursement Policy, this procedure is not eligible for reimbursement with the reported diagnosis". The diagnosis codes we used are M54.5, M54.2, M79.1 and S33.5XXA. Has the denial anything to do with the diagnosis codes we used? Per Blue Cross' policy, 99354 is payable. I've attached a Blue Cross' policy link for your review. https://www.bluecrossmn.com/healthy/public/portalcomponents/PublicContentServlet?contentId=P11GA_15091624
SuperCoder Answered Tue 03rd of April, 2018 03:13:39 AM

Yes, as per attached policy link 99354 is payble and there is nothing mentioned about diagnosis codes. But there is a line in coverage policy that review of tests with the patient only is not considered prolonged care and as such will be denied.

If provider is spending extra time for reviewing test than blue cross policy says its not billable.

If that is not the case, Please check your documentation and appeal with documentation that must identify and describe the procedures performed. The time in face-to-face contact with the patient must be noted. The plan of care must also be present and support the need for prolonged care. Submit the documentation with appeal.

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