Outpatient Prolonged Service Codes - Medicare Billing
Medicare allows office visit coding and billing based on time, rather than intensity of services, when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face physician/patient encounter or the floor time, in the case of inpatient services. In addition, there are add-on codes identified as prolonged services that are used for even greater extensions of the face-to-face portion of the visit during an evaluation and management (E&M) service.
Codes such as CPT 99354 (Prolonged physician service in the office or other outpatient setting requiring direct, face-to-face patient contact beyond the usual service) describe services 30-74 minutes over the average minutes allotted to the base E&M visit.
As a general rule, when a visit is extended in time due to counseling and coordination of care, and this is more than 50 percent of the time of service, then time shall govern the coding of the office visit, per Center’s for Medicaid Services (CMS). This usually results in billing for CPT 99215 or other high-level visits based on time. Use of the add-on prolonged service codes, like 99354 after 30 minutes beyond this high level E&M service, would occur only if additional medically necessary and documented face-to-face patient services are provided.
For example: The patient has a 10-minute office service with low level examination and decision making, and sixty-five minutes of medically necessary counseling. You would not code the office visit as 99212-Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history; a problem focused examination; straightforward medical decision making and would typically involve 10 minutes face to face with the patient. You would code it as 99215 (typically spend 40 minutes face to face with the patient) because of the rule that time is the controlling element. In this example, there are 75 minutes of patient contact time, of which 40 is allotted to 99215. The remaining 35 minutes would fall under the prolonged service code, in this example, of an office setting, CPT 99354. CPT 99354 would be billed in addition to CPT 99215 in this example. Prolonged service of less than 30 minutes total duration on a given date is not separately reported because the work involved is included in the total work of the E&M code.
An additional Prolonged Service code exists for use in the outpatient setting. CPT 99355 – each additional 30 minutes. If the example above exceeded 74 minutes over the average minutes allotted to the base E&M, this code would be added to the codes described above for each additional 30 minutes.
Questions? Contact Neil Walsh at ext. 2-9377 or cwalsh6@partners.org