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  
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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.

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