Home Q&A Billing for prolonged services

Billing for prolonged services

November 2010

Published in the November 2010 issue of Today’s Hospitalist

CAN’T FIGURE OUT HOW TO BILL FOR PROLONGED SERVICES? You’re not alone. That’s one of the issues I tackle in this month’s column, along with billing for student dictations and critical care services.

Billing for prolonged services
I’m not clear on whether time spent with families or reviewing test results can be used to calculate time spent on prolonged services (99356-99357). Does all the time spent on prolonged services have to be face-to-face with the patient? Also, I’ve read that we’re required to write down start and stop times. Is this mandatory, or is documenting total time in the medical record on prolonged services enough?

Guidelines from the CMS state that Medicare will not recognize prolonged services without the face-to-face interaction, and many other payers have followed suit. Time spent with the family or reviewing tests and labs qualifies as face-to-face if those activities are done while the patient is in the room. But if those activities are performed in the hall, they cannot be counted toward the total time of prolonged services.

There are CPT codes that physicians can use to designate services “without direct (face to face) patient contact,” but the CMS does not attach any RVUs to those codes. That means that Medicare doesn’t pay for them either.

And no, you don’t need to document start and stop times to bill for prolonged services, nor do those services have to be continuous. Below is a helpful cheat sheet to use when calculating prolonged service time. (While Medicare discontinued consult codes earlier this year, I’ve included these codes in the chart because many private payers still use them.)

Students and discharge summaries
At our facility, we train fourth-year medical students during a clerkship to dictate discharge summaries. We’ve advised faculty to edit those dictations for accuracy and to document on the summaries that they did a face-to-face evaluation of patients on the day of discharge.

We’ve been coding most of these as a 99238 (low-level discharge management services), and we indicate the number of minutes spent over 30 minutes when we code a 99239 (high-level discharge management services). But recently, a new coder in our group has stopped billing for these discharge summaries. Even though we have attending attestations, the coder’s concern is that a discharge summary shouldn’t be completed by a student.

I agree with your new coder. Students can operate as scribes, but they can’t bill for full dictations on their own. (Payers recognize attending attestations only with residents, not medical students.) It’s great to give students early training in dictation, but you can’t bill public or private payers for that service unless it’s a resident doing the dictation with a supervising physician.

Critical care services
One of our staff doctors documented critical care services for an eye injury. May we honor that and charge for critical care services? Or do we have to downcode to either initial hospital care or a subsequent visit (in the case of an established patient) if we can’t consider the eyes a single “vital” organ system?

The AMA defines critical care as “the direct delivery by a physician of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition. Critical care involves high-complexity decision making to assess, manipulate, and support vital system function to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.”

The CMS adds that for services to qualify as critical care for Medicare patients, “the failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient’s condition.”

While the eyes are considered part of the nervous system, they are not considered to be vital. (Vital organs include the heart, kidney, spleen, lungs and liver.)

Examples of organ system failure include central nervous system failure; shock; or circulatory, acute renal, acute hepatic, acute metabolic, or respiratory failure. In the case of an audit, it may be hard to defend critical care services for a visual system failure.

High-level codes
One of our hospitalists charged a level 99223 (high-level initial hospital care), and his documentation supports that. However, he also documented spending 50% of his time “30 minutes “on coordination of care, which (according to CPT guidelines) would qualify only for a 99221 (low-level initial hospital care). May we charge a level 99223?

Yes, as long as his history, exam and medical decision-making meet the criteria of the higher code.

Tamra McLain is client services manager with MedData Inc. E-mail her your documentation and coding questions at tamram@meddata.com. We’ll answer your questions in a future issue of Today’s Hospitalist.