Prolonged service billing

I have a question about the appropriate use of the outpatient prolonged care codes. Here is the possible scenario: provider is seeing the patient for the first time. Patient is new to provider but not new to our group (seen within 3 years by provider in group-same specialty). Very thorough examination and review of previous records is done with patient. We will say that the visit is a 99214 and the total time spent with the patient was 60 minutes. Is it appropriate to use the prolonged care code in this situation? Provider does take a lot of time with the patients but I am not sure that this is a good enough reason to use the prolonged care codes. Any thoughts are appreciated! Thank you.

prolonged service

CPT code 99214 is indicated for an "office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history, a detailed examination and medical decision making of moderate complexity."
You may count only the duration of direct face-to-face contact with the patient (whether the service was continuous or not) beyond the typical/average time of the visit code billed
You can only bill the prolonged services codes if the total duration of all physician direct face-to-face service (including the visit) equals or exceeds the threshold time for the evaluation and management service the physician provided (typical/average time associated with the CPT E/M code plus 30 minutes).
You need 55 minutes of face-face time documented to bill 99214 and 99354.

Prolonged service billing

Thank you. I guess what I am trying to ask is this: if a physician chooses to spend an extended amount of time with patients because he/she likes to take time with the patients, is it appropriate to bill prolonged care?

For example, one physician may take 25 minutes for a visit but it might take a different physician 60 minutes for the same visit. Is it appropriate to be using the prolonged care codes for the physician who is taking longer?

prolonged service

All services must be medically necessary, there is usually a documented reason as to why the encounter was prolonged AFTER the key components were met.

Use the code!

You don't tell us the medical problem; I could envision a 99213 with a prolonged service code. Take diabetes; a very thorough discussion with teaching could take 45 minutes. The diabetes meets level 3 with no tests ordered, one established diagnosis. Why use a 99214 or 99215 based on time when 99213 and 99354 is more appropriate and pays better?

Prolonged service billing

I think if we have a situation where there are lengthy counseling discussions with the patient (for example regarding diabetes) we would have to use the highest E/M level (e.g. 99215) and then only use the prolonged care code if the visit was at least 30 minutes longer than the "typical" time for 99215 (40 minutes).

I think you can add the prolonged care codes on to any level E/M if you are monitoring/treating the patient but if you are using the extra time for counseling I think you have to first get to the highest level E/M and add prolonged care as appropriate from there.

If you could use prolonged care for the counseling following a 99212 (e.g.) what would prevent everyone from using this code combination all the time instead of increasing your E/M level based on time and choose a 99215?

I am having a difficult time understanding this and need to explain it to one of our providers. I really appreciate any discussion we can have on this topic to help me understand it correctly.

Thank you.

So you'd think...

Your logic makes great sense BUT CMS says I'm right :-) Look at page 9 on this document http://www.cms.hhs.gov/transmittals/downloads/R1490CP.pdf and you will see the table. I use the complexity of the presenting problem to guide my code choice and then add the prolonged services code if over 30 min extra. So a mole is 99212, hypertension is 99213, diabetes and hypertension is 99214 and metastatic cancer warrants 99214-5. Any other opinions?

Prolonged service billing

I have reviewed that document and actually have distributed it in the past to all of our providers. I think the key to this would be...what was the reason for the extra 30 minutes or more? On page 12 of the document, section H, it explains that if counseling/coordination of care dominates the visit you must choose your code based on time so you cannot add prolonged care codes unless you choose the highest level E/M and then go over the time by 30 minutes.

In your example, if you were seeing a patient for hypertension and were choosing a 99213 for your visit (15 minutes) but were with the patient for 45 minutes counseling the patient about the hypertension, your visit would be more than 50% counseling which would mean you would need to choose your code based on time rather than choosing the lower level visit and adding the prolonged care code on. (according to the CMS document).

I really appreciate hearing your side of this issue. As I said above, I really think the key is "why" was the extra time spent. If it was for monitoring or treating the patient I completely agree that the lower code (if appropriate) would be chosen and then the prolonged care code could be added. However, if the reason for the extended visit was counseling/coordination of care we would choose the E/M based on time and go from there.

Do you have any other thoughts or scenarios? This is frustrating because I don't want to tell my providers to bill in a way that is not correct but I also do not want to walk away from appropriate reimbursement (which is what the insurance companies would prefer us to do!).

Thank you.

Om my...

this is so confusing!! As I should have done earlier, I read the whole article and you are correct. So...how do you do a 99213 and have face-to-face of 45 min that is not counseling? I guess diabetic teaching is not technically counseling. Reviewing chemotherapy options with use of risk charts and side effects, etc could be considered care planning and not counseling. I WELCOME input from coders out there!!!!

prolonged service billing

What I understand from this discussion is if time is used for mainly treating the patient then use the lowest E&M code and add the prolonged service code verses counseling where you choose highest E & M code 99215 plus prolonged service code.
My question is if provider spent 60 minutes face to face and it was more than 50% counseling, can he choose 99215 based on time even if the exam and history were at expanded problem level? I am confused.

Thanks and sorry, confused, just new and preparing for my CCS exam.

prolonged services

The article is on this website, in the encyclopedia section of Codapedia.

Type in the word prolonged in the search box above "Look it up!" and you'll find it.

We really need CMS to clarify this

It is so confusing- their table lists prolonged services times for 99201-205 and 99212-99215 yet they also say you should not use the prolonged codes until you get to the highest level code 99215 or 99205. Do Editor or Nancy have any connections to get an answer from CMS or an intermediary? Perhaps a few concrete examples...

prolonged service

the prolonged service codes can be used on any level of E/M code, once 30 minutes have elapsed. They are not limited to 99205 and 99215.

prolonged services

Prolonged services are confusing.

If the visit is all counseling, then you use the normal E/M services based on time. If the visit is all counseling, and the visit is 30 minutes longer than typical time for the highest visit in that category, then you use the E/M and prolonged.

But, say it's a patient for whom you take some history, do a limited exam, and then the rest of the visit is counseling. Maybe it's a patient with a breast lump, and you take her breast history, family history, GU ROS, exam the breast. The visit would audit (let's just say) as a 99214. This visit is not all counseling. You spend 60 minutes with the patient. Bill 99214 (typical time 25 minutes) and the prolonged services, 30 minutes, meeting the threshold time of 55 minutes.

Now, say this patient returns to discuss again her options. You don't take any history. You don't re-examine her. The entire visit is counseling. This visit is 50 minutes long. You would bill 99215 and no prolonged services code. Why? The visit was all counseling. The typical time for a 99215 is 40 minutes. You didn't meet the threshold for prolonged services with 99215, which would be 40 plus 30 minutes, or 70 minutes.

Does that help?

Prolonged Service

I did not read anything that said that if the visit is all counseling then you code based on time. I read the instruction to say that if more than 50% of the visit is spent counseling/coordination of care you choose the E/M based on time and then add the prolonged service code as appropriate.

In the example given, if you have the 60 minute visit with the patient and spent 30 minutes counseling/coordination of care would you really be able to choose the 99214 (based on the hx, exam and MDM) and then add the prolonged code for the extra 30 minutes?... or would you have to choose 99215 based on time (40 minutes) because 50% of visit was counseling?

The example given makes sense (all counseling versus some counseling) but I just cannot find that instruction written anywhere. I'm sorry to continue questioning but I really need to clarify this for my providers.

Thank you.

Prolonged services

If you look at the articles in the database, you will see the citation to the Medicare Claims Processing Manual. Look at Pub 100-04, chapter 12, section 30.6.15.

It's in there.

Prolonged Service

Thank you for your response. In one of the examples given in the Medicare Claims Processing Manual it states: "A physician performed a visit that met the definition of an office visit code 99213 and the total duration of the direct face-to-face services (including the visit) was 65 minutes. The physician bills code 99213 and one unit of code 99354."....I am still trying to clarify what the physician was doing for the 50 minutes beyond the normal time for the 99213 (15 minutes). If the additional 50 minutes was spent talking with the patient about treatment options, etc., wouldn't we then have to choose our code based on time because counseling/coordination of care dominated (was more than 50%) of the visit?

This excerpt is from the same section of the Medicare Claims Processing Manual: "When an evaluation and management service is dominated by counseling and/or coordination of care (the counseling and/or coordination of care represents more than 50% of the total time with the patient) in a face-to-face encounter between the physician or qualified NPP and the patient in the office/clinic or the floor time (in the scenario of an inpatient service), then the evaluation and management code is selected based on the typical/average time associated with the code levels. The time approximation must meet or exceed the specific CPT code billed (determined by the typical/average time associated with the evaluation and management code) and should not be “rounded” to the next higher level.

In those evaluation and management services in which the code level is selected based on time, prolonged services may only be reported with the highest code level in that family of codes as the companion code."

I'm not sure if I am making my question clear. I guess I am trying to think of an example of what a physician would be doing in that extra time besides counseling the patient and if the physician is counseling the patient for more than 50% of the visit the instruction tells us to choose the code based on time (same as CPT instruction).

patient present

You may count only the duration of direct face-to-face contact with the patient (whether the service was continuous or not) beyond the typical/average time of the visit code billed, to determine whether prolonged services can be billed and to determine the prolonged services codes that are allowable.
You cannot bill as prolonged services:
• In the office setting, time spent by office staff with the patient, or time the patient remains unaccompanied in the office; or
• In the hospital setting, time spent reviewing charts or discussing the patient with house medical staff and not with direct face-to-face contact with the patient or waiting for test results, for changes in the patient’s condition, for end of a therapy, or for use of facilities.

In the prolonged service codes a patient encounter was performed and subsequent to that, the physician had medically necessary, face-to-face interaction with the patient. Example: monitoring a patient in hypoglycemic episode or titration of drug for emergent condition. each interaction must be documented, if not continuous, and the time beyond 30 minutes (first hour) of average time stated for the encounter code starts the prolonged service time.

prolonged services

And, there are two fairly new articles in the database:

search prolonged in the search box above, "Look it up!" and read the two articles on prolonged services in an inpatient setting, and prolonged services in an outpatient setting.