cpt codes 99354 - 99357

Prolonged Physician Service with Direct (Face-to-Face) Patient Contact (99354-99357)


Codes 99354-99357 are used when a physician provides prolonged service involving direct (face-to-face) patient contact that is beyond the usual service in either the inpatient or outpatient setting. This service is reported in addition to the designated evaluation and management services at any level and any other physician services provided at the same session as evaluation and management services. Appropriate codes should be selected for supplies provided or procedures performed in the care of the patient during this period.

Codes 99354-99355 are used to report the total duration of face-to-face time spent by a physician on a given date providing prolonged service, even if the time spent by the physician on that date is not continuous. Codes 99356-99357 are used to report the total duration of unit time spent by a physician on a given date providing prolonged service to a patient, even if the time spent by the physician on that date is not continuous.

Code 99354 or 99356 is used to report the first hour of prolonged service on a given date, depending on the place of service.

Either code should be used only once per date, even if the time spent by the physician is not continuous on that date. 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 evaluation and management codes.

Code 99355 or 99357 is used to report each additional 30 minutes beyond the first hour, depending on the place of service. Either code may also be used to report the final 15-30 minutes of prolonged service on a given date. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.

The use of the time based add-on codes requires that the primary evaluation and management service have a typical or specified time published in the CPT codebook.

The following examples illustrate the correct reporting of prolonged physician service with direct patient contact in the office setting:

Total Duration of Prolonged Services    Code(s)

less than 30 minutes   -  Not reported separately

30-74 minutes (30 minutes - 1 hr. 14 min.)  -  99354 X 1

75-104 (1 hr. 15 min. - 1 hr. 44 min.)  - 99354 X 1 AND 99355 X 1

105 or more (1 hr. 45 min. or more)  -  99354 X 1 AND 99355 X 2 or more for each additional 30 minutes




99354Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management service)

(Use 99354 in conjunction with 99201-99215, 99241-99245, 99324-99337, 99341-99350, 90809, 90815)

99355Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service;each additional 30 minutes (List separately in addition to code for prolonged physician service)

(Use 99355 in conjunction with 99354)

99356Prolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient Evaluation and Management service)

(Use 99356 in conjunction with 99221-99233, 99251-99255, 99304-99310, 90822, 90829)

99357Prolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual service;each additional 30 minutes (List separately in addition to code for prolonged physician service)

(Use 99357 in conjunction with 99356)

Use of Prolonged service Codes

Prolonged services codes can be billed only if the total duration of all physician or qualified NPP direct face-to-face service (including the visit) equals or exceeds the threshold time for the evaluation and management service the physician or qualified NPP provided (typical/average time associated with the CPT E/M code plus 30 minutes).

If the total duration of direct face-to-face time does not equal or exceed the threshold time for the level of evaluation and management service the physician or qualified NPP provided, the physician or qualified NPP may not bill for prolonged services.

Threshold Times for Codes 99354 and 99355 (Office or Other Outpatient Setting)
If the total direct face-to-face time equals or exceeds the threshold time for code 99354, but is less than the threshold time for code 99355, the physician should bill the evaluation and management visit code and code 99354. No more than one unit of 99354 is acceptable, additional units will be denied as non-covered. A provider cannot bill the member for the non-covered service.

If the total direct face-to-face time equals or exceeds the threshold time for code 99355 by no more than 29 minutes, the physician should bill the visit code 99354 and one unit of code 99355. One additional unit of code 99355 is billed for each additional increment of 30 minutes extended duration.

The following threshold times will be used to determine if the prolonged services codes 99354 and/or 99355 can be billed with the office or other outpatient settings including domiciliary, rest home, or custodial care services and home services codes.

Threshold Time for Prolonged Visit Codes 99354 and/or 99355 Billed with Office/Outpatient Codes




Add 30 minutes to the threshold time for billing codes 99354 and 99355 to get the threshold time for billing code 99354 and two units of code 99355. For example, to bill code 99354 and two units of code 99355 when billing a code 99205, the threshold time is 150 minutes.

REPORTING ADDITIONAL PROLONGED SERVICES CPT 99355

CPT-4 Code 99355 To report additional prolonged outpatient E&M services, CPT-4 code 99355 (each additional 30 minutes) must be billed in conjunction with code 99354.


Billing Calculations CPT-4 codes 99354 and 99355 are subject to the least restrictive frequency limitation as the required companion code. To calculate the amount of time that is payable for prolonged outpatient services, take the total face-to-face time and subtract the time of the primary E&M service. The following table may be used to calculate billing for prolonged outpatient E&M services.

.

Time of E&M visit code not included First hour Each additional 30 minutes

Less than 30 minutes Not reported Not reported

30 – 74 minutes 99354 Not reported

75 – 104 minutes 99354 99355

105 – 134 minutes 99354 99355 (quantity of 2)

135 – 164 minutes 99354 99355 (quantity of 3)

165 – 194 minutes 99354 99355 (quantity of 4)



Inpatient ServicesCPT-4 Code 99356 - To report prolonged inpatient E&M services, CPT-4 codes 99356 (inpatient setting; first hour) must be billed in conjunction with one of the following E&M service codes:



Description & CPT-4 Code

Initial hospital care and subsequent hospital care

99221 – 99223
99231 – 99233

Inpatient consultation
99251 – 99255

Nursing facility services
99304 – 99310

Inpatient psychotherapy with E&M component
90822, 90829

Prolonged Physician Service Without Direct (Face-To-Face) Patient Contact (99358-99359)

Codes 99358 and 99359 are used when a physician provides prolonged service not involving direct (face-to-face) care that is beyond the usual non-face-to-face component of physician service time.

This service is to be reported in relation to other physician services, including evaluation and management services at any level. This prolonged service may be reported on a different date than the primary service to which it is related. For example, extensive record review may relate to a previous evaluation and management service performed earlier and commences upon receipt of past records. However, it must relate to a service or patient where direct (face-to-face) patient care has occurred or will occur and relate to ongoing patient management. A typical time for the primary service need not be established within CPT code set.

Codes 99358 and 99359 are used to report the total duration of non-face-to-face time spent by a physician on a given date providing prolonged service, even if the time spent by the physician on that date is not continuous. Code 99358 is used to report the first hour of prolonged service on a given date regardless of the place of service. It should be used only once per date.

Prolonged service of less than 30 minutes total duration on a given date is not separately reported.

Code 99359 is used to report each additional 30 minutes beyond the first hour regardless of the place of service. It may also be used to report the final 15 to 30 minutes of prolonged service on a given date.

Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.

Do not report 99358-99359 for time spent in medical team conferences, on-line medical evaluations, care plan oversight services, anticoagulation management, or other non-face-to-face services that have more specific codes and no upper time limit in the CPT code set. Codes 99358-99359 may be reported when related to other non-face-to-face services codes that have a published maximum time (eg, telephone services).

99358Prolonged evaluation and management service before and/or after direct (face-to-face) patient care; first hour

99359Prolonged evaluation and management service before and/or after direct (face-to-face) patient care;each additional 30 minutes (List separately in addition to code for prolonged physician service) (Use 99359 in conjunction with 99358)

EHR timeline by Medicare

Proposed meaningful use timeline changes encourage adoption of EHRs


In response to significant input from multiple stakeholders, expert testimony, and countless hours of review, analysis and deliberation, the Department of Health & Human Services (HHS) announced its intention to delay the start of stage 2 meaningful use for the Medicare and Medicaid electronic health record (EHR) incentive programs for a period of one year for those first attesting to meaningful use in 2011. The Centers for Medicare & Medicaid Services (CMS) intends to propose such a delay in the stage 2 meaningful use notice of proposed rule making (NPRM), which is scheduled to be published in February 2012.


Why did CMS make this decision?

Input from the vendor community and the provider community makes clear that the current schedule for compliance with stage 2 meaningful use objectives in 2013 poses a challenge for those who are attesting to meaningful use in 2011.

The current timetable would require EHR vendors to design, develop, and release new functionality, and for providers to upgrade, implement, and begin using the new functionality as early as October 2012.



What are the benefits to the proposed delay?

CMS believes that a proposed delay will be beneficial for several reasons:

• CMS hopes that this will give vendors added time to develop certified EHR technologies for stage 2, as well as give providers additional time to implement new software and meet the new requirements of stage 2.

• CMS also intends to propose maintaining the current expectation for those first attesting to meaningful use in 2012, so that all providers attesting to meaningful use in 2011 or 2012 will begin stage 2 in 2014.

• CMS believes this provides an added incentive for providers to attest to meaningful use in 2011 and rewards early participants.

Under the Medicare and Medicaid EHR incentive programs, providers who attest early receive greater incentives. And now those providers who first attest in 2011 are eligible for three payment years for meeting the stage 1 criteria, while those first attesting in 2012 can only have two payment years under stage 1 criteria.



Are Medicaid program participants affected?

Because Medicaid providers can receive an incentive payment for adopting, implementing, or upgrading to certified EHR technology in their first year of Medicaid EHR incentive program participation, Medicaid providers will still be able to attest to stage 1 meaningful use for the next two years (first for a 90-day period, then for a 365-day period).

Therefore, most Medicaid providers do not attest to stage 2 requirements until 2014 at the earliest.