Prolonged Services Its Not Just About Time

Time, as it applies to E/M codes, has often been viewed as an "if/then" proposition. "If" the documentation shows that a majority of the encounter was based on counseling and/or coordination of care, "then" we choose the highest level of service based on the total time of the encounter.

However, a lingering question remains when we follow such a rigid model; what if the complexity of the visit doesn't rise to the level of service matched by the total time? This tension becomes more severe when the total time of the encounter spills into the addition of prolonged services codes. 

As coders and auditors, we have had at least 23 years of being told by CMS that "medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code". This being the standard, it stands to reason that the application of time as a factor in billing should still require deference to the complexity of the visit.

One way of looking at this is to take note of the threshold times for prolonged services that have been in effect by CMS since the implementation of Change Request 5972 on July 1, 2008 (summarized in Medicare Learning Network Matters article MM5972, which is found here). An auditor will immediately notice that there are threshold times for every E/M code, rather than the codes of the highest level. The reason for this is that CMS anticipates that there will be visits that are dominated by counseling that will fall short of the complexity required to report high-level codes.

As an illustrative example, a patient returns to the physician's office for a discussion of laboratory and MRI results. While the complexity of the service is low, the patient has several questions regarding the care he/she is about to receive. The total time of the encounter totals 45 minutes, with no exam performed.

In this example, it would be tempting to assign CPT code 99215, as the patient spent over 40 minutes of face-to-face time with the physician, but the acuity of the visit is still low. The better option in this case would be to bill CPT code 99213 along with CPT code 99354 for the first 30 to 74 minutes of prolonged services, in order for the complexity of the visit to be properly reported.

One last point needs to be made regarding prolonged services. Much like critical care codes, the initial CPT codes for prolonged services include the description "first hour", but this does indeed represent the first 30 to 74 minutes. If 64 minutes of prolonged services are performed, only one code is reported. If 75 or more minutes are reported, this requires the reporting of two codes, with the second representing only an additional 1-30 minutes of prolonged services time.

This Week's Audit Tip Written By:  

J. Paul Spencer, COC, CPC

Paul Spencer is a Senior Compliance Consultant with our parent organization, DoctorsManagement

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