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Stacy Posted Mon 19th of February, 2018 08:59:49 AM
How must the prolonged care time be documented to meet Medicare's Medlearn Matters 5972 requirement for prolonged care in the hospital setting (codes 99356 & 99357)?
SuperCoder Answered Tue 20th of February, 2018 03:30:19 AM

According to the MM5972, in the inpatient setting, Medicare will pay for prolonged physician services (code 99356) (with direct face-to-face patient contact which require one hour beyond the usual service), when billed on the same day by the same physician or qualified NPP as the companion evaluation and management codes. You should report each additional 30 minutes of direct face-to-face patient contact following the first hour of prolonged services may be reported by CPT code 99357.



Required Codes with Prolonged Services:

The companion E&M codes for 99356 are the Initial Hospital Care and Subsequent Hospital Care codes (99221-99223, 99231–99233), the Inpatient Consultation codes (99251–99255); Nursing Facility Services codes (99304-99318).

The companion codes for 99357 are 99356 and one of its required E&M codes.



Presence of Physician:

Only countable duration of direct face-to-face contact with the patient (whether the service was continuous or not) beyond the typical/average time of the visit code billed, to determine whether prolonged services can be billed and to determine the prolonged services codes that are allowable.


Prolonged services cannot be billed in the following scenarios:

-In the office setting, time spent by office staff with the patient, or time the patient remains unaccompanied in the office; or

-In the hospital setting, time spent reviewing charts or discussing the patient with house medical staff and not with direct face-to-face contact with the patient or waiting for test results, for changes in the patient’s condition, for end of a therapy, or for use of facilities.



Note: Prolonged service should not be separately reported of less than 30 minutes total duration on a given date, because the work involved is included in the total work of the evaluation & management (E&M) codes.

You may use code 99355 or 99357 to report each additional 30 minutes beyond the first hour of prolonged services, based on the place of service. These codes may be used to report the final 15–30 minutes of prolonged service on a given date, if not otherwise billed. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.


Also, it must be appropriately and sufficiently document in the medical record that you personally furnished the direct face-to-face time with the patient specified in the CPT code definitions. Make sure that you document the start and end times of the visit, along with the date of service.

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