Published in the November 2004 issue of Today’s Hospitalist
In August 2004, I wrote about the time-based codes you can use to report critical care services. What do you do, however, when an evaluation and management service exceeds the normal standards of time and the patient is not defined as critically ill or critically injured?
For patients who require more management because of a medical, family or social issue–or any combination of the three–CPT offers prolonged services codes. (For a guide to normal timeframes for inpatient codes, see “How much time is that inpatient code worth?” on the next page.)
The time requirements for prolonged services are similar to those for critical care services codes. The codes are strictly based on time and patient location (inpatient vs. outpatient), and they vary based on whether the service involves direct, or face-to-face, patient contact.
Because Medicare does not recognize prolonged services that do not involve face-to-face contact, I’ll focus on the documentation guidelines and reimbursement process for prolonged services with face-to-face patient contact.
When reporting these types of services, you need to remember some key points. For one, prolonged services are “add-on” codes, which means you can not use them by themselves. You must first report the appropriate evaluation and management service code based on the amount of history, exam and medical decision-making.
You can use prolonged service codes to report any time that exceeds the time included in evaluation and management service codes–as long as it is at least 30 minutes. (For an example of how to calculate additional time, see “The time requirements of prolonged services codes,” below.)
To report any additional time spent with a patient, the service needs to fall on the same calendar date. The services you are reporting, however, do not have to be continuous, and you can combine the time spent on services throughout the day into one block of time.
In addition, when you report additional time, you can report total duration and don’t have to break the extra time into smaller units. If you use code 99357, however, you can’t count blocks of extra time that amount to less than 15 minutes because they don’t meet the criteria of the code.
One other point: While Medicare recognizes the effort that goes into prolonged services, it doesn’t expect to see the codes used very often.
With that in mind, you should carefully document time in the medical record to show how the service exceeded the normal time requirements. Payers may deny these codes on first submission, but submitting an appeal and including documentation will normally push the claim through.
Because these codes are fairly new, payers vary in the fees they pay and how much they’ll scrutinize your use of the codes. Perseverance, along with proper documentation, is the key to making sure you’re reimbursed for the extra time you spend in the form of prolonged services.
Tamra McLain can be reached through e-mail.