Published in the June 2014 issue of Today’s Hospitalist
When spending extended time with patients, is it OK to simply increase our level of coding from, say, a subsequent visit level 2 to a level 3? Or should we code the visit at a certain level and then add a prolonged service code (99356-99357)? We are wondering why we need to submit two codes, one for the subsequent visit and one for prolonged services, instead of just “upcoding” to a higher-level code.
This is a great question because prolonged services can be a real challenge to understand.
So don’t consider “upcoding” an option. Instead, there are two correct approaches to prolonged services: documentation of key components and documentation of time. Let’s review them both.
The first approach is to document the level of history, exam and medical decision-making that was clinically appropriate and medically necessary. Based on these key components, doctors then select a level of an E/M code “and each E/M code has been assigned an approximate time value. You can find these approximate times in the E/M codes section of the CPT manual.
The prolonged service codes were developed to accurately reflect time and clinical efforts that exceed the typical parameters defined by evaluation and management (E/M) codes. But “upcoding” is a definite no-no. It may place physicians at increased audit risk because it artificially skews the typical coding patterns and percentages that the Centers for Medicare and Medicaid Services assign to E/M codes.
When you rely on key components to select a level of service and you think the use of a prolonged care code is appropriate, use the approximate time associated with that level of service as the threshold time for prolonged care. But here’s the catch: You may not bill for the first hour of prolonged care unless you spend 30 minutes or more beyond the approximate time assigned to the E/M service level you’ve chosen.
Say you round on an inpatient and, after documenting history, exam and medical decision-making, choose a subsequent care code 99232. That code has an approximate time of 25 minutes, which becomes the benchmark.
You would not be able to report an inpatient prolonged care code 99356 (prolonged service in the inpatient or observation setting, face-to-face time with the patient, first hour) until the total time for the encounter hits 55 minutes. That 55 minutes includes the approximate E/M-service time of 25 minutes and the minimum of 30 additional face-to-face minutes for the prolonged care service.
Here’s another wrinkle: Medicare’s definition of prolonged care differs from that of CPT in terms of using prolonged care codes. According to Medicare, the time used to report prolonged care must be face-to-face with the patient, even in the hospital setting. Most third-party payers likewise follow Medicare guidance because it is easier to apply a single standard than to ask providers to bill according to a patient’s health plan requirements.
Physicians have another option for choosing an E/M service and using a prolonged care code: basing that choice solely on time. You may choose that option when more than 50% of your face-to-face time with a patient in the hospital (or in an office, for that matter) is spent in counseling and/or coordination of care.
In this scenario, you must document that you selected an E/M service level based on spending more than 50% of the total encounter time face-to-face with the patient in counseling or care coordination.
And when using time as the sole factor for your selection when you are also reporting prolonged care, you must bill the highest level of service in that particular E/M code set.
Here’s an example: Say you spend 40 minutes at the patient’s bedside discussing a new diagnosis of lung cancer. You then spend an additional 10 minutes examining the patient, plus another 25 minutes face-to-face with the patient and family discussing treatment options and nutrition.
Based on an E/M visit where more than 50% of the total time was spent face-to-face with the patient in counseling or coordination of care, you would bill a subsequent hospital visit 99233, the highest level in that category. But CPT code 99233 has an approximate time of only 35 minutes, while your total encounter was 75 minutes. You should therefore bill using 99233 (35 minutes) and 99356 (prolonged care up to one hour).
Your documentation should include not only the total face-to-face time spent, but also a brief summary of the content of the counseling: “I spent 75 minutes face-to-face with the patient and family discussing the patient’s new diagnosis of lung cancer and outlining various treatment options available.”
But what if your total amount of prolonged service on any given date is less than 30 minutes? You can’t separately report or bill for that time. Instead, the (less than 30 minutes of) additional work is just considered part of your E/M service.
Sue A. Lewis, RN, CPC, PCS, is a coding manager for a nonproﬁt health plan in the Midwest. Send any billing and coding questions you have to her at email@example.com and we may answer them in a future issue.