Auditing Prolonged Evaluation and Management Services

At times, there are patients who require prolonged face-to-face time with the provider to discuss or be counseled about their condition, plan of care, risks, complications, alternative therapies, or other medical issues. When E/M services go wild, taking significantly longer than the typical time associated with it, that direct face-to-face time with the provider may qualify for Prolonged Evaluation and Management service coding and additional reimbursement.

These services are not regularly reported; however, if you’ve noticed an uptick in the amount of times these codes are being reported in your practice, it may be time for an audit. Understanding the rules associated with how and when these codes should be reported will allow you to train and educate the providers and staff responsible for selecting them.

Do a quick review of your compliance plan to see if there is a current policy for these codes. If one does not exist, consider creating one. By adding new policies and updating old ones, you will demonstrate that your office has a living and active compliance plan in place. Updates to policies should be in writing with effective dates noted when new or updated policies replace old ones.

Prolonged E/M Services are time-based codes and can only be reported after a base E/M service code has been selected. In other words, these codes are add-on codes (as noted by the + symbol in front of the codes in the codebook). 

The total time documented is based only on the direct, face-to-face time the provider spends with the patient. The following codes are used to report Prolonged Evaluation and Management services: 

Office/Other Outpatient Setting (direct face-to-face services)

• 99354 for the first hour (beyond the time linked to the base E/M service)

          (report only after a minimum of 30 minutes beyond the time linked to the base E/M service)

• 99355 each additional 30 minutes beyond the first hour 

         (report only after the full 60 minutes for 99355 has been reached & exceeded by 15 minutes) 

Inpatient Setting (direct face-to-face services)

• 99356 for the first hour 

         (report only after a minimum of 30 minutes beyond the time linked to the base E/M service)

• 99357 each additional 30 minutes beyond the first hour 

         (report only after the full 60 minutes for 99355 has been reached & exceeded by 15 minutes)

What the Documentation Should Include

As these are time-based codes, time must be documented, preferably using start and stop times, which may be mandatory based on the payer. Time can be accumulated or continuous, and if accumulated, it should be documented and then added together for a total time.

Calculate only direct face-to-face contact between provider and patient. Guidance from both CPT^® and Medicare are noted below. Check with your Medicare Administrative Contractor (MAC) for guidance specific to your region.

Office/Other Outpatient: 

CPT^® and Medicare agree that time should be calculated based on direct face-to-face time (accumulated or continuous) with the provider.

Inpatient or Skilled Nursing: 

CPT^® states time can be calculated at the bedside and on the patient’s floor or unit in the hospital or nursing facility (whether continuous or not); however, Medicare is a little more definitive, stating “time spent reviewing charts or discussion of a 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” cannot be counted as direct, face-to-face time.  (Medicare Claims Processing Manual 30.6.15.1.C)

Services can only be reported after a qualifying, time-based, E/M service code or psychotherapy code has been reported and the typical time associated with that code has been deducted from the overall, direct, face-to-face time of the encounter. Documentation must include a summary of what was counseled, or coordinated, with the patient along with the start/stop times for face-to-face services. The basic E/M code may be determined on components or on time alone, and then any remaining time may be used to determine whether a prolonged E/M code can be reported.

Calculating the Base E/M Service

Component based E/M is determined by reviewing the key components (history, exam, and medical decision making) to determine the level of E/M code the documentation qualifies for. The typical time associated with the selected E/M code is then deducted from the total direct, face-to-face time and any remaining time is evaluated to determine whether it qualifies for a Prolonged E/M service. The following examples have been reviewed based on the Physician Fee Schedule for Utah.

Example 1:  

The provider reported codes 99212 ($42.47) and 99354 ($129.16).

The documentation for an established patient E/M service reveals a problem focused history and examination and low complexity medical decision making, which qualifies for 99212 based on components. The documentation identifies a summary of what was discussed and direct face-to-face with the provider from 10:45 - 11:10 (total 25 minutes).

The typical time spent face-to-face for code 99212 is 10 minutes. Subtract the 10 minutes from the total time (25-10) and the remaining time is 15 minutes, which can be used towards a Prolonged E/M code if all other applicable criteria has been met.

According to the rules associated with Prolonged E/M service code 99354, in order to qualify for one unit the provider would have to spend an additional 30 minutes beyond the selected base E/M typical service time. 

“Prolonged service of less than 30 minutes total duration on a given date is not separately reported because the work involved in included in the total work of the evaluation and management or psychotherapy codes.” (CPT Prolonged Services Guidelines-2017).

In this case, there were only 15 minutes beyond the base E/M code, so it would not qualify. However, the provider doesn’t just throw away the 15 minutes spent giving personal attention to the patient. Instead, calculate the service based on time only. The total time is 25 minutes, which, based on time (and documentation), qualifies for an E/M service of 99214 and properly reimburses the provider for his time.

The service should have been billed as 99214 ($105.49) indicating an overpayment of $66.14. If you were auditing this report, it would be wise to correct your coding and consider resubmission of a corrected claim.

Example 2: 

The following codes were reported: 99213 ($71.60), 99354 ($129.16). 

The documentation for an outpatient office visit for an established patient E/M service reveals an expanded problem focused history, problem focused exam, and low complexity decision making, qualifying it for code 99213 based on components. The documentation identifies a summary of what was discussed and direct face-to-face time with the provider was noted from 3:20 to 4:15 (total 55 minutes).

The typical time spent face-to-face for code 99213 is 15 minutes. Subtract the 15 minutes from the total time (55-15) and the remaining time is 40 minutes, which can be used towards a Prolonged E/M code if it qualifies. The minimum time requirement to qualify for one unit of 99354 is 30 minutes, qualifying for one unit of 99354 with 10 minutes leftover. However, since 99354 has a max time of 60 minutes, the leftover 10 minutes would not qualify for any additional units or codes. This service was coded correctly.

Now, you review one for yourself and see if you come up with the right answer: 

Example 1:

The following services have been billed: 99232 ($72.25), 99356 ($91.87), 99357 ($91.87) 

Documentation reveals the provider performed a subsequent hospital E/M service for a patient who was admitted for complications associated with his diabetes. The documentation revealed an expanded problem focused history and examination, and moderate complexity decision making, qualifying it for code 99232 based on components. Documentation also revealed a summary of what was discussed with the patient. The documented time was 2:05 pm - 3:20 pm (75  minutes). 

Consider the following: 

1.  Was this encounter coded correctly? 

2.  Is there a better way to code this for maximum reimbursement? 

Answer:

Incorrectly billed: 

Time was incorrectly calculated because the typical time associated with the EM code 99232 (25 minutes) was not deducted before applying time to the Prolonged E/M service codes, subjecting this claim to an overpayment and all that entails.

Correct billing options:

This service could be coded in two different ways. 

Component-based: Subtract the typical time from the total time documented (75-25), which leaves 50 minutes, which qualifies for one unit of 99356. In order to have qualified for the one unit of 99357, the time documented would have had to be 75 minutes beyond the time deducted for the basic E/M code time.

Time-based: Use the total face-to-face time (75 minutes) to determine the overall coding. To code by time, code to the highest code level for the given service and location, which in this case is subsequent hospital care code 99233 (35 minutes). Subtract the 35 minutes from the total time, (75-35) and the remaining time is 40 minutes, which can be counted towards a Prolonged E/M service, garnering about $30.00 more than if you calculated your base E/M service by components.

Taking the time to understand the coding and guidelines associated with Prolonged Evaluation and Management services can help your practice cover the cost associated with patients whose complications or detailed individualized attention take up more time than expected. Beware, though, that Evaluation and Management services are highly scrutinized by Medicare and any excessive reporting of Prolonged Evaluation and Management services could quickly turn into a request for medical records for auditing purposes, so be sure to use these codes appropriately and wisely. 

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