If you’re billing based on time, you may be able to report prolonged care for office visits (+99354, Prolonged service 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 service]). If the physician’s prolonged time went beyond an hour, check whether you can also submit +99355 (…each additional 30 minutes [List separately in addition to code for prolonged service]). Note that prolonged service of less than 30 minutes on a given date is not separately reportable.
Key: The physician needs to document the time, such as with a statement similar to, “I spent an additional ______ minutes with the patient. We discussed ______.” That helps your coding, plus gives the documentation necessary during an audit. You’ll also report the appropriate office visit code, since +99354 and +99355 are add-on codes.
Coders sometimes think the patient must be in the hospital or nursing facility to use the prolonged services codes, but that’s not the case. You can report +99354 and +99355 for any extended office or outpatient evaluation and management (E/M) service, if you have sufficient documentation of the time. Some patients with complex conditions or multiple health concerns require more time than others. Prolonged service codes can apply if the physician documents the total time spent with the patient and what was discussed, and it is 30 minutes or more than the typical time associated with the base E/M code.
Example: Let’s say that in your physician’s situation that the encounter otherwise merits reporting a 99214 based on the history, exam, and medical decision making involved in the encounter. That code has a typical time of 25 minutes in CPT. However, because of the need to review the hospital notes and medication lists with the patient and family in this case, let’s say the physician actually spent 60 minutes in the visit. In that scenario, the prolonged time is 35 minutes (60 – 25 = 35), which exceeds the 30 minute threshold for reporting prolonged services and is enough to justify reporting +99354. The principle works the same way if the level of service for the visit code is chosen on the basis of time (i.e. because the encounter was dominated by counseling and coordination of care).
Code 99205 (Office or other outpatient visit for the evaluation and management of a new patient ... Physicians typically spend 60 minutes face-to-face with the patient and/or family) requires 60 minutes of face-to-face time. But if your physician spent 91 minutes with the patient, then you can bill 99205 for the first 60 minutes plus +99354 to capture payment for the extra time.
Remember that codes +99354-+99357 are time-based and are add-on codes. You do not need to append a modifier to these codes and you should not decrease their reimbursement when billed with other primary E/M codes.
Important: Remember that there is a 30-minute threshold time with the prolonged services codes before those codes kick in. In other words, include 30 minutes more beyond the usual time for the reported E/M service before using the prolonged services codes.
In this case, you should report 99205 for the first 60 minutes, add 30 minutes threshold time making the time for the initial visit 90 minutes, and then add +99354 for the additional minutes .