Learn when and what CPT codes to use with prolonged services codes 99354 and 99355 at your medical practice.
"I was in the exam room forever with that patient. Is there any way I can bill for that time?" Is there a clinician in the country who hasn't asked that question? And the answer usually involves someone - the clinician or staff member - searching through the CPT book.
There are CPT codes for prolonged services that a physician or non-physician practitioner (NPP) can report in addition to an evaluation and management (E&M) service for face-to-face time that is 30 minutes more than the typical time for that service. There are two sets of prolonged services codes that are paid by most insurers, including Medicare. These are 99354 and 99355 for office services, and 99356 and 99357 for facility services. This article discusses only office prolonged services. There are CPT codes for non-face-to-face services but they have a bundled status indicator in the Medicare Fee Schedule and are not reimbursed by Medicare or most payers.
The time must be the billing clinician's face-to-face time with the patient. Staff time doesn't count. The time a patient spends getting a nebulizer treatment while the clinician sees another patient doesn't count. Time that the physician spends on the phone outside the exam room coordinating care with the oncologist doesn't count. The time that matters is direct face-to-face time spent with the patient by the billing provider.
The prolonged services codes are add-on codes. That means, they may not be reported (that is, submitted on the claim form) alone. They must always be added on to another code. In this case, added on to specific E&M code and to only those companion codes listed in the CPT book after the descriptor for that code. These include new and established patient visits (99201-99215), office consultations, (99241-99245), Domiciliary, Rest Home, or Custodial Care services (99324-99328, 99334-99337) and Home Services codes (99341-99345, 99347-99350). Use prolonged services codes 99354 and 99355 only with these CPT codes.
One of the reasons that prolonged services are reported infrequently is because the threshold time to use the codes varies by each of the companion codes with which they can be used. The minimum time for reporting prolonged services is 30 minutes more than the typical time for the E&M code. Since the typical time for each of the E&M codes is different, the threshold time is different. Chapter 12 of the CMS Claims Processing Manual, Section 30.6.15 has a chart that shows the threshold time for using prolonged services with each level of E&M code. Download Chapter 12 of manual 100-04, found at http://www.cms.gov/Manuals/IOM/list.asp
A common question is how to bill for an established visit that lasts 45 minutes. Should the clinician select 99215, (typical time 40 minutes) or should the clinician select 99213 (typical time 15 minutes) and 99354 (30 minutes of prolonged services)? For counseling visits, select the E&M service based on the total duration of the time, in this case, 99215. For services that are entirely counseling, only use prolonged services if the threshold time for the highest level of service in that category is met, plus the additional 30 minutes. However, if the visit consisted of an expanded problem focused history, an expanded problem focused exam, and low medical decision making - which meet the criteria for a 99213 - but the visit took 45 minutes to perform, bill 99213 and 99354.
The length of time spent must be medically necessary. CPT requires the total time of the visit to be documented. For Medicare patients, Medicare requires the start and stop time of the visit in order to report prolonged services. Clinicians can and should bill for prolonged services. Print out the chart from the Medicare Claims Processing Manual referenced above, and note the total time in the medical record for non-Medicare patients, and start and stop times for Medicare patients.
Betsy Nicoletti is the founder of Codapedia.com. She is the author of “A Field Guide to Physician Coding.” She believes all physicians can improve their compliance and increase their revenue through better coding. She may be reached at firstname.lastname@example.org or 802 885 5641.