According to a recent report in Medical Economics, prolonged services are on the rise. Reporting prolonged services can be tricky because of the time criteria involved. Physicians and medical billing and coding service providers need to be knowledgeable about the codes to report prolonged services as well as the billing requirements to ensure appropriate reimbursement.
Prolonged services begin once the typical time as per CPT guidelines has elapsed for the Evaluation and Management (E/M) service. Prior to 2017, Medicare reimbursement was limited to face-to-face prolonged services. The report notes that Medicare reimbursement for face-to-face prolonged services rose from a national average of $100.97 in 2016 to $131.15. Starting January 2017, Medicare began paying for non-face-to-face prolonged services, with a national average reimbursement rate of $113.41.
Face to face prolonged service codes
Codes 99354-99357 are used when a physician or other qualified health provider performs a prolonged service involving direct (face-to-face) patient contact that goes beyond the usual service in either the inpatient or outpatient (office, clinic, observation, etc.) setting.
- 99354 Prolonged service in an office or other outpatient setting with direct patient contact, first hour
- 99355 Each additional 30 minutes
- 99356 Inpatient place of service code for the first hour of prolonged services. This code should be used only once per date, and prolonged services must exceed 30 minutes in order to report it.
- 99357 Inpatient place of service code for each additional 30 minutes beyond the first 60 minutes of prolonged services. Additional services provided must exceed 15 minutes in order to report this code.
Note: Medicare will not pay prolonged services codes 99354-99357 unless they are accompanied by the appropriate companion codes or E/M service codes. The primary E/M code must have a typical or specified time as designated by CPT guidelines.
Non face-to-face prolonged service codes
- 99358 Prolonged evaluation and management service before and/or after direct patient care; first hour
- +99359 (Each additional 30 minutes; to be listed separately in addition to code for prolonged service)
Note: As a prerequisite for payment, Medicare requires that non-face-to-face prolonged services are provided on the same date of service as the E/M code or on a date of service thereafter
Although the payment for prolonged services increased, the Office of Inspector General’s (OIG) Work Plan for 2017 states that these services are considered “rare and unusual.” This implies that providers should provide evidence that they had a definite and compelling reason to bill prolonged services. Moreover, many commercial payers bundle prolonged services into the payment for the E/M service and deny payment for the prolonged service codes or look for additional documentation before they make payment.
Documentation in the medical record should include
- Details about the duration and content of the medically necessary E/M service and prolonged services that are billed
- Appropriate and sufficient document in the medical record that the physician personally provided the direct face-to-face time with the patient specified in the CPT code definitions
- Start and end times of the visit, along with the date of service
- Proof of the time spent rendering prolonged services and the tasks that the physician performed during that time
Physicians should also know that the following cannot be billed for prolonged services:
- Care plan oversight
- Waiting for test results
- Waiting for changes in the patient’s condition
- Waiting for end of a therapy
- Waiting for use of facilities
- Anticoagulant management
- Medical team conferences
- Online medical evaluations or other non-face-to-face services that have more specific CPT codes
Physicians should know about Medicare’s rules on the threshold time for billing CPT codes 99354 and 99355 with an outpatient visit code. When billing prolonged services, they should also be aware about the unique requirements and policies of commercial payers.
With such complexities involves, physicians can benefit greatly with professional support. An experienced medical billing and coding company can ensure correct coding and reporting of prolonged physician or other qualified health care provider service with direct and without patient contact in the office/hospital setting.
Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.