Coding Cues: Reporting extended visit codes

Key Points

Our practice has never billed for extended visits, but we often spend a great deal of time counseling patients. How do we go about reporting extended visit codes? What else needs to be documented besides the history, exam, and medical decision-making?

Choosing a level of care on the basis of time requires that more than 50 percent of the encounter be spent in counseling. While you may document a history, exam, and medical decision-making, it's most important to document how much time was spent with the patient and the topics discussed. In addition, the calculation must be for face-to-face time; time spent reviewing medical records, researching reference books, etc., even in an inpatient setting, doesn't count unless the visit is reported based upon counseling and coordination of care.

Keep in mind, too, that prolonged service codes (99354-99355) are in addition to the time assigned to the E&M level of service and can only be reported in conjunction with the highest level of E&M. Consider the example of a patient who comes in for a low-level follow-up exam, then discloses that her husband was recently diagnosed with cancer and she needs to talk about what to expect and how to cope. The total encounter time ends up being 90 minutes, with over half spent in counseling. The appropriate coding would be the highest level of established patient E&M service, or 99215 (typically 40 minutes of face-to-face time). In addition, code 99354 (prolonged physician service; first hour) would be reported.

The author, vice president of operations for Reed Medical Systems in Monroe, MI, has more than 30 years' experience as a practice management consultant, as well as being a certified coding specialist, certified compliance officer, and a certified medical assistant.