Published in the May 2009 issue of Today’s Hospitalist
ON THE SURFACE, prolonged service codes seem to be fairly straightforward. You use the codes to bill for services that significantly exceed the standard time you typically spend providing care.
Related article: Related article: Updated ICD-9 Codes for 2012
But the reality is that very few code sets cause more confusion. In part, that’s because some prolonged service codes can be used only in the outpatient setting, while others are strictly for inpatient care. Further, some codes are for non-face-to-face services (which Medicare and most other carriers typically won’t pay), while others require face-to-face care.
We’re going to look at the two prolonged service codes that hospitalists use most often: 99356 (the first hour of prolonged inpatient face-to-face services) and 99357 (each additional 30 minutes beyond that first hour).
Be sure to bill any prolonged services that you provide, but I recommend against automatically using these codes when seeing patients more than once a day as part of routine rounding. Read the following rules and caveats carefully to make sure you don’t overuse these codes—and invite unwanted scrutiny.
What are prolonged service codes?
Prolonged service codes are add-on codes billed with the primary evaluation and management (E/M) service, such as an initial or subsequent visit.
You can use these codes even if the prolonged services have been provided by different physicians within your group. (In that case, add the prolonged service code or codes to the E/M code for the physician who’s billing the hospital visit for that day.) You must provide the prolonged services on the same calendar day as the E/M service.
You would bill these codes when treating patients whose symptoms are especially complex and concerning: patients with cardiac arrhythmias, for example, or those in whom you suspect possible emboli, or patients who have multiple injuries or are comatose. When you realize that you need to spend significantly more time than usual with a patient, start watching the clock and keeping track of how long the service takes.
To bill a 99356 alone or with a 99357, the time spent with the patient does not have to be continuous. It must, however, all be spent on one calendar day and face-to-face.
Counting the minutes
You can use prolonged service codes with any level of E/M code, based on the history, exam and medical decision- making provided—except for counseling. (See the discussion on counseling, which follows.) But to bill a 99356, you must spend at least 30 minutes more than the typical time established for that particular E/M code. (See “Time thresholds for prolonged service codes,” below.) If the time spent is less than 30 minutes beyond that threshold, you cannot bill a prolonged service code. Instead, consider that time when deciding what level of E/M service to bill for that patient that day.
Before billing a 99357 for an additional 30 minutes, you must spend at least 15 minutes beyond the first hour you’re already charging. Confused? Here’s an example:
According to the AMA’s CPT book, the typical time spent providing a level 2 subsequent visit is 25 minutes. To bill a 99356, you need to spend at least 55 minutes face-to-face with that patient on that day. That includes the 25 minutes for the level 2 subsequent visit plus at least 30 additional minutes.
Before billing a 99357, you must spend more than 100 minutes with that patient: the 25 minutes considered typical for the level 2 subsequent visit; plus the 60 minutes of prolonged services covered by the 99356 code; plus at least 15 minutes of the additional 30 minutes of prolonged services.
When billing for a service that meets the 100-minute time threshold, submit all three codes on the claim form: the E/M code, which in this case would be 99232 (level 2 subsequent visit), and the 99356 and 99357 codes.
Prolonged counseling services
In addition to patient treatment or monitoring, you can use these codes to cover lengthy counseling discussions with patients on treatment options, disease processes, or the medical necessity of procedures or tests.
In these scenarios, however, the time spent on face-to-face counseling must dominate more than 50% of the visit. Further, you must first meet the time threshold for the highest code level in the E/M category you’re billing. This distinguishes the use of prolonged service codes for counseling vs. treatment or monitoring, where you can add these codes to any level of E/M service.
Say you want to bill a 99356 for prolonged counseling services during a subsequent visit. First, make sure that counseling comprises at least half the typical time spent for a level 3 subsequent visit (99233), which is 35 minutes.
Then, you must spend at least 35 additional minutes face-to-face counseling the patient—to satisfy the 50%- plus time requirement—before you can bill a 99356.
Ground rules and caveats
While these codes don’t require any modifiers, they all need meticulous documentation. Note in the chart the total amount of time spent face-to-face with the patient and why that time was needed.
And one final piece of advice: Use these codes judiciously. Because the codes entitle you to additional reimbursement, insurance carriers give these claims extra scrutiny. They may want to review your records to see if the claim is substantiated, how you documented the time spent, whether the service was medically necessary and if it included only face-to-face patient time.
The Centers for Medicare and Medicaid Services has stated that it does not expect to see these codes used routinely. If you’re in the habit of billing these codes on virtually every patient you round on, expect your charges to be challenged.
Kristy Welker is an independent medical coding consultant based in San Diego. E-mail your documentation and coding questions to her at email@example.com. We’ll try to answer your questions in a future issue of Today’s Hospitalist.