Prolonged Services in an inpatient setting

July 31st, 2009 - Codapedia Editor
Categories:   CPT® Coding   Primary Care|Family Care   E-prescribing   Medicare   Medicare Claims Processing Manual  
0 Votes - Sign in to vote or comment.

This article will describe the coding for using prolonged services in an inpatient setting.  The codes are 99356: Prolonged physician service in the inpatient setting, first hour and 99357 each additional 30 minutes.  See the CPT® book for the complete descriptions.

These codes are used as add on codes with only these services, according to the CPT® book:

99221--99233 Initial hospital visit codes and subseuquent hospital visit codes

99251--99255 Inpatient consultation codes

99304--99310 Initial nursing facility codes and subsequent nursing facility codes

90822 and 90829, two psych codes for which the typical time is 75-80 minutes

For an inpatient, a physician may not add the prolonged services codes to any other services.  They may not be used with observation or ED services, or with any procedure.

CMS and CPT® instruct us to use these codes differently.  In 2009, CPT® changed its definition of the correct use of these add on codes to "requiring unit/floor time beyond the usual service" while CMS still requires that to use the prolonged services codes there be an additional 30 minutes of "face-to-face" time, not unit time.  Their description in the manuals did not change with the CPT® description. In CPT® Changes 2009--An Insider's View CPT® gives the rational for this, saying they have revised the description in this way, "...while the inpatient codes are intended to report the total duration of the time spent (continuous or non-continuous) by the physician on the unit."

This makes sense from a coding perspective.  Unfortunately, CMS does not agree. There manual instructions continue to emphasize that in order to use the prolonged services codes, the additional time must be face-to-face: (Medicare Claims Processing Manual, Pub 100-04, Chapter 12, Section 30.6.15

Physicians may count only the duration of direct face-to-face contact between the physician and 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.

And, CMS states:

The start and end times of the visit shall be documented in the medical record along with the date of service.

In addition, physicians need to be aware of the typical time for the code, and add the prolonged services codes only when the total time (including the additional 30 minutes of face-to-face time if it is a Medicare patient) meets the threshold. There is a pdf file attached as a resource to this article which shows the typical times for each code, and the threshold times required to use the prolonged services codes.

The time spent in prolonged services does not need to be "more than 50% in discussion of..." as it does for selecting an E/M service based on time. This is a source of further confusion. 

Hospitalists often ask how they can use prolonged services when one physician in the group sees the patient in the morning, and another sees the patient in the evening.  Only one hospital visit may be billed in a single day.  If the first physician documents the time of the initial encounter in the record, and it meets the typical time for the level of service billed, and the second physician spends 30 minutes additional face-to-face time with the patient (for Medicare) and documents time in the record, the second physician could bill prolonged services.  Use caution here!  Make sure that there is medical necessity for prolonged care, and that the visits both have time clearly documented.  The second visit should explicitly state the time was face-to-face for a Medicare patient.  An unusual use of prolonged services codes will certainly get the attention of your payers.

Key points:

  • This is an article about inpatient prolonged services.  There are a limited number of codes, listed above, for which a clinician may add the prolonged services codes.
  •  CMS and CPT® rules for inpatient prolonged services are not the same.  CMS requires that the additional prolonged services for an inpatient be face-to-face, not unit time.
  • Use the codes when the time is 30 minutes more than the typical time for the visit.  This means the threshold time for using prolonged services changes for each visit. 
  • The chart in the CPT® book is confusing.  There is a chart attached to this article, and in the CMS manual, that lists each code and the threshold times for prolonged services.
  • Document time in the medical record.
  • Use caution when billing prolonged services for a second physician visit (for coverage).  Both physician notes must have time documented.
  • An unusually high use of these codes invites a payer audit.


Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.

Latest articles:  (any category)

Coding for a Performance of an X-ray Service vs. Counting the Work as a Part of MDM
March 21st, 2022 - Stephanie Allard , CPC, CEMA, RHIT
When x-rays are audited on the same date as an E/M encounter we have one of three decisions to make about the work that went into the radiological exam when the practice owns x-ray equipment and does their own interpretations internally. First, we must determine whether the x-ray was...
Continuous Glucose Monitoring (CGM) Systems: Leveraging Everyday Tech to Enhance Diabetes Management
March 16th, 2022 - Susan Gatehouse, RHIT, CCS,CPC, AHIMA-Approved ICD-10-CM/PCS Trainer
However, is the coding for the treatment and management of diabetes being adequately captured? Diabetes mellitus (DM) affects over 400 million people worldwide. It is a chronic disease of inadequate control of blood levels of glucose that affects the body’s ability to turn food into energy. Essentially, the...
ESRD Hemodialysis Hits Home with the New ETC Model
March 16th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
In 2021, two major ESRD programs became effective, essentially preparing to transform not only risk adjusted services, but also at-home dialysis, health equity among beneficiaries needing transplant services, and improved access to donor kidneys.
Refresh Your IV Hydration Coding Knowledge
March 16th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Reporting IV infusion services can be complicated, especially when multiple infusions are reported in a single encounter. Take a few minutes to freshen up your knowledge on IV hydration coding with a review of the guidelines and a few coding scenarios.
Medicare Auditors Caught Double-Dipping
March 14th, 2022 - Edward Roche, PhD, JD
Overlapping extrapolations require providers to pay twice. Some Medicare auditors have been caught “double-dipping,” the practice of sampling and extrapolating against the same set of claims. This is like getting two traffic tickets for a single instance of running a red light. This seedy practice doubles the amount...
Cybersecurity & Ransomware Warnings
March 10th, 2022 - Wyn Staheli, Director of Content
Although HIPAA Security protocols have been in effect for some time, as technology advances, if we are not diligent, gaps can be left available for intruders. On top of that, on February 23, 2022, the American Hospital Association issued a cybersecurity advisory. They stated, “there is concern that Russia may retaliate against the U.S. and allied nations with disruptive cyberattacks.”
The Case of the Missing Signature
March 10th, 2022 - David M. Glaser, Esq.
It’s important to remember that Medicare manuals are not binding, and they can’t “require” anything, including signatures. Regulatory framework is constantly changing. Never assume you know all of the rules, even if you carefully study them all the time. New things are constantly appearing....

Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2022 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association