The good news is that payment for prolonged services rose in 2017. The bad news is that the feds are taking a closer look at use of these codes.
• 99354 (Prolonged service in an office or other outpatient setting with direct patient contact, first hour)
• 99355 (Each additional 30 minutes)
• 99358 (Prolonged service without direct patient contact, first hour)
• 99359 (Each additional 30 minutes)
Payment information: Medicare reimbursement for face-to-face prolonged services increased from a national average of $100.97 in 2016 to $131.15. Medicare began paying for non-face-to-face prolonged services as of January 1, 2017, reimbursing a national average of $113.41.
Although payment for prolonged services went up, the bad news is that these services are also on the Office of Inspector General’s (OIG) Work Plan for 2017, an annual report that summarizes the OIG’s new and ongoing reviews and activities to reduce fraud, waste, and abuse related to various Department of Health and Human Services programs and operations. In the document, the OIG states that prolonged services are considered “rare and unusual.”
This means physicians who bill these services must have a clear and compelling reason to do so, says Raemarie Jimenez, CPC, CPC-I, vice president of membership and certification solutions at AAPC, an organization representing professional coders, billers, auditors, compliance professionals, documentation specialists and practice managers. “If you’re going to bill these services, there needs to be a summary of what you were doing to prolong that care,” she adds.
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With that said, many commercial payers continue to deny payment for these codes because they bundle them into the payment for the evaluation and management (E/M) service, says Kathleen Mueller, RN, CPC, president of AskMueller Consulting LLC, a healthcare consulting company. Rather than deny claims outright, some payers (including Medicare) may require additional documentation before rendering payment, says Mueller. They’re typically looking for proof of the time spent rendering the service and what tasks the physician performed during that time.
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She provides this example of documentation that would satisfy Medicare requirements for face-to-face prolonged services: Patient presents with an acute exacerbation of asthma. Patient stayed in the office for an extra 65 minutes to receive intravenous medication and undergo monitoring until stable.
To correctly bill for this scenario, Mueller suggests separating the documentation for the prolonged service from the rest of the visit with a note. Then report CPT code 99354 and the appropriate E/M code with modifier -25. She suggests including the start and stop time for the prolonged service in box 19 on the CMS-1500 claim form (e.g., 10:40 a.m. to 11:45 a.m.). This documentation may prevent the payer from asking for additional information, she adds.
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Jimenez agrees that documentation of the time spent is critical. “Whenever it’s a time-based service, I always recommend that the provider include the start and stop times because then if you’re audited, there’s no question about the time it took,” she adds.
Physicians also need to remember that prolonged services don’t include care plan oversight, anticoagulant management, medical team conferences, online medical evaluations or other non-face-to-face services that have more specific CPT codes, says Jimenez.
Non-face-to-face prolonged services could include extensive record reviews or communication with other providers, says Kim Huey, MJ, CHC, CPC, an independent coding and reimbursement consultant. These prolonged services must be related to another E/M service that has occurred or will occur, and to ongoing patient management. Even though this isn’t stated in CPT, Huey says Medicare requires as a prerequisite for payment that non-face-to-face prolonged services are rendered on the same date of service as the E/M code or on a date of service thereafter.
Remember that prolonged services begin once the typical time (per CPT guidelines) has elapsed for the E/M service, says Mueller. For example, CPT code 99214 usually requires 25 minutes. This means physicians shouldn’t bill for prolonged services unless they provide an additional 30 minutes or more of evaluation and management. Medicare provides a guide for helping physicians determine the threshold time for billing CPT codes 99354 and 99355 with an outpatient visit code at bit.ly/prolonged-codes. Note that this guide includes a link to updated coverage information at http://bit.ly/MM9905.
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However, commercial payers may have their own unique requirements, says Mike Strong, MBA, CPC, bill review technical specialist at SFM, a workers’ compensation insurer. For example, if a physician spends 60 minutes counseling the patient, a payer may require the physician to report CPT code 99215 (which includes 40 minutes or more of counseling and coordination of care) rather than CPT code 99214 with a prolonged services add-on code, he adds. Practices should check with a payer to determine its policy.