Published in the April 2007 issue of Today’s Hospitalist
When it comes to coding and documentation, I keep hearing this same question from hospitalists: How do I document patients who require more time than I typically bill for with evaluation and management (E/M) codes, but who aren’t sick enough to warrant using critical care codes, which give credit for time spent?
The answer comes in the form of prolonged services codes. These CPT codes have time requirements that are similar to critical care codes, but with some key differences.
When using prolonged services codes, you must keep the following three elements in mind:
- Outpatient vs. inpatient. Is the patient sitting in the emergency room, and you’ve been called in to advise on a particularly difficult scenario? Or has the patient been admitted, and you’re in the middle of rounding or consults? You would use an outpatient code in the first instance and an inpatient code in the latter.
- Time and duration of service. How much time did you spend with the patient? You have to document time and follow certain protocols to be able to bill prolonged services codes. While prolonged services don’t need to be provided in a continuous block of time on any one day, you can bill only one "initial hour" per calendar day and must bill any subsequent time as "each additional 30 minutes."
- Face-to-face contact. Have you spent additional time directly with the patient, or have you spent that time reviewing records and communicating with other professionals and the patient’s family?
Addressing the first element “outpatient vs. inpatient setting “is simply a matter of matching the right code and setting. But because the next two elements require more thought, I’ll focus on the details of time and of face-to-face contact.
Time and duration of service
To successfully use prolonged services codes, you need to know how much time is typically required for E/M codes. That’s because you use prolonged services codes to document the time you spend on patient care above and beyond the time spelled out in E/M codes.
When using prolonged services codes, note that you must bill the E/M service as the primary service. Prolonged services are defined by CPT as "add-on" codes, so you should never submit only a prolonged services code for services performed.
The specific CPT prolonged services codes are listed in "Prolonged services codes and time required." As you look over the list, note that the amount of time specified by each code refers to time above and beyond what’s required by the E/M code you’re reporting as the primary service.
Also note that prolonged services of less than 30 minutes total duration on a given date are not separately reported. For example, say you perform a level 2 history and physical (CPT 99222: 50 minutes), but it takes 85 minutes. You can appropriately code CPT 99222 and 99356 to account for the extra 35 minutes.
If you spend a total of only 75 minutes with the patient, however, the 25-minute period beyond what’s included in CPT 99222 would not be separately reportable. That’s because it does not meet the greater-than-30-minute requirement.
Here’s another rule to keep in mind: Prolonged services of less than 15 minutes beyond the first hour, or less than 15 minutes beyond the final 30 minutes, are not reported separately.
Medicare doesn’t pay physicians for prolonged services that don’t involve face-to-face contact. But if you review the list of prolonged services codes, you’ll note that the last two “CPT codes 99358 and 99359 “specify prolonged services provided before or after direct patient care.
If this seems like a contradiction, here’s the explanation. While the Centers for Medicare and Medicaid Services (CMS) recognize prolonged services, even those that don’t involve face-to-face contact, it does not pay physicians for that work as a separate reimbursed service. Instead, the CMS considers those services part of the E/M services physicians are already billing.
When using prolonged services codes 99354-99357, count only the time spent in direct face-to-face contact with the patient beyond the typical time called for by the E/M code. According to CMS rules for prolonged services in the hospital, you cannot count any time spent waiting for test results, for changes in the patient’s condition, for the end of a therapy or for the use of facilities.
However, you can attribute time spent providing non-face-to-face prolonged services to a review of extensive records or tests, and to communication with other professionals and/or the patient or family.
To illustrate the finer points of using prolonged services codes, CPT offers the following table to illustrate the time considerations of CPT 99354 and 99355:
Total duration of prolonged services/codes:
- Less than 30 minutes: not reported separately
- 30-74 minutes: 99354
- 75-104 minutes: 99354 X 1 and 99355 X 1
- 105-134 minutes: 99354 X 1 and 99355 X 2
Finally, remember that you can use prolonged services codes with not only the highest level E/M codes but with low and moderate level codes as well.
Tamra McLain is an independent coding consultant in Southern California. E-mail your documentation and coding questions to her or send a fax to 888-202-1601. We’ll answer your questions in a future issue of Today’s Hospitalist.