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Prolonged Service Codes

Robert Posted Wed 21st of April, 2010 23:08:08 PM

Csn someone please help me with this questions:
First, can the prolonged codes 99354 & 99355 be billed with all E/M codes ranging from (99211-99215)?

Secondly, What if a physician see's a patient for 60 min, would you bill 99214 with 99354? Supercoder says the 99254 is the first additional hour after the allowed E/M code time but when I talk to Medicare they said 99354 can be used for the first additional 30 min. and add the 99355 to add each additional 30 min. after that. Can someone please clarify?

SuperCoder Answered Thu 22nd of April, 2010 08:09:51 AM

Answer for the first question, you can bill an E/M code that has a time component (such as 99201-99215, Office or other outpatient visit …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. Also note that a prolonged time occurs at the time of the preventive annual exam cannot be reported separately.
For the second question The physician cannot code 99214, which has a typical time of 25 minutes, and one unit of code 99354. The physician must bill the highest level code in the code family (99215, which is associated with 40 minutes typical/average time units). The additional time the physician spends beyond this code is 20 minutes, which does not meet the prolonged service code +99354’s “threshold” time of 30-74 minutes. So you don’t need to report a prolonged service code in this situation.
Cpt 99354 is billed only when the total duration service is 30-74 minutes, where as 99355 is used for each additional 30 mins. The CPT text book provides a table for the prolonged services which I hope would provide more info and clear view about how to code during these type of services.

Robert Posted Tue 27th of April, 2010 19:29:43 PM

Thanks Alex: very very much. What you said is the way I first read the methodology. My office manager however disagreed, stating that any E/M code could be used and the prolonged CPTs added, as long as the E/M criteria and Prolonged time were met for at least 70 min. I have second inquiry as well...
A patient with a Chief Complaint and multiple co-morbid pathologies, non-English speaking, no m.d. visit for 1-2 years, off previous meds, and #4 very significanjt ICD-9 dx'x is seen in the office. In my practice, this might occur with 1-2 patients each day (we have a large Asian and Hispanic population). We're probably also addressing a psychiatric dx as well. The 99215 + 99255 CPT codes as per MDMother criteria and time factor are not that uncommon. Yet, I've read that in a typical Primary practice that CMS estimates that approximately 1:1000 claims/per M.D. would be expected and qualify for payment. Meeting all criteria, I would be submitting 4-5 of these E/M - Prolonged claims a WEEK. Will I be a Sitting Duct for a Red Flag and probable audit? An audit would be unremarkable if conducted, but who wants to be flagged and audited? What's your take? ....... AlwaysNdenial

Robert Posted Tue 27th of April, 2010 23:16:58 PM

This is the website straight off Medicare's website where my office manager found information conflicting with what you have mentioned. Looks like something that we need to look into.$FIle/MM6740_RevisionsConsultationServicesPaymentPolicy.pdf
(refer to page 6)

SuperCoder Answered Thu 29th of April, 2010 21:57:59 PM

Robert and Alex,
A few points need to be clarified so you're not mixing apples and oranges :)
1. CPT 2009 deleted modifier 21, which was a prolonged service modifier that could be used on only the highest EM level in a given category. You could use modifier 21 on only 99205, 99215, 99233, etc. (highest time based code in a series).
The highest category pertains to +99354 and +99355 in only one situation: time based EM coding. When you're using time based coding because counseling and/or coordination of care dominates the service, you have to code based on the service's total face-to-face time. Since you would select the code based on the total time, you would only use prolonged services if you had reached the threshold for the highest level code and still had uncaptured minutes totaling 30 minutes or more.
Let's look at Robert's example of a 60 minute established patient office visit. If you spent and documented more than 30 minutes on counseling/coordination of care, you would select 99215. as Alex indicated, you would only have 20 more uncaptured minutes, which you could not capture.

SuperCoder Answered Thu 29th of April, 2010 22:06:23 PM

If, however, Robert performed 99214 based on the service's key components of history, exam, and medical decision making, but the visit for some medically necessary documented reason took 60 minutes rather than the average 25 minutes that physicians usually spend performing this service, you would code 99214 and +99354 to capture the additional uncaptured 35 minutes.
So your office manager and the Medicare contractor time's are correct provided you are selecting the base code based on HEM, not time. When selecting the code based on time, you bill the highest level and then use a prolonged service code to capture any additional over the threshold minutes.

SuperCoder Answered Thu 29th of April, 2010 22:10:59 PM

While your usage will be above a typical practice's EM bell curve, you have extenuating circumstances. Make sure your documentation supports your outlier status.
Your documentation should indicate why the service took longer than usual (non-native speaker). In Pediatric Coding Alert, Dr. Tuck has often explained that patients with a foreign language often qualify as poor historian's which is part of the CMS standard audit sheet data points that count toward higher medical decision making. So this protocol of having higher level visits due to nonnative population is documented.
Jen Godreau, CPC, CPEDC
Content Director,

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