How physicians can improve coding and increase revenue

Reimbursement for evaluation and management (EM) services is often the most challenging for primary care physicians and their billing staff. The most common EM codes are based on location, patient status, and level of service.

A good understanding of the opportunities, and a review of common errors found in audits, will help your practice obtain payment and peace of mind.

Prolonged Services

The 2016 Office of the Inspector General Work Plan includes a warning that the government plans to audit claims for CPT 99354-99356 for prolonged services with or without direct patient contact.

Prolonged services are for additional care provided to a beneficiary after an EM service has been performed. Physicians submit claims for prolonged services when they spend time in addition to the time spent with a beneficiary for a usual companion EM service. The necessity of prolonged services is considered to be unusual.

 

Related: Skimping on financial advice could prove highly foolish for physicians

 

Apply the codes if:  the time is documented; it is medically necessary; and the provider was attending the patient the entire time (e.g. for chest pain or respiratory distress.)  The codes should not be used if the provider was in and out seeing other patients during the time interval. Direct (face-to-face) patient contact is required. Only count the time spent face-to-face, even if the time is not continuous.

Prolonged service CPT codes 99354 and 99355 were revised in 2016 to report EM or psychotherapy services and can now be reported with 90837 (psychotherapy) as well as 99201-99215 (office visits), 99241-99245 (outpatient consultations), 99324-99337 (residential/assisted living) and 99341-99350 (home services)

The 2016 CPT included the new code 99415. It covers prolonged clinical staff service (service beyond the typical service time) during an EM visit in the office or outpatient setting, direct patient contact with physician supervision; first hour (list separately in addition to code for outpatient EM service). Use code 99416 for reporting each additional 30 minutes. The prolonged services codes cannot be reported for more than two patients at the same time.

Common errors: Audits of claims for prolonged services frequently show that this “time-based” code is not supported by documentation of time. Prolonged service code(s) may be added to a base EM code only by the rendering provider. 

Prolonged service codes cannot be used to represent cumulative episodes of care by multiple, same-specialty providers within a group. While there is no required time format, many carriers recommend clock time (for example, 11 a.m. to 11:45 a.m.) but will also accept time documented as “45 minutes was spent.” The note should support how the time was spent.

Internal server error