CPT 99354 – Prolonged 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) - average fee payment - $100 - $120
Providers should report each additional 30 minutes of direct face-to-face patient contact following the first hour of prolonged services by using CPT code 99355.
The average reimbursement is in the range of $95.00, depending upon your region.
The Medicare Manual says:
The start and end times of the visit shall be documented in the medical record along with the date of service.
This code is one of many under-utilized codes in your office for many reasons. However, if you do the work and spend the prolonged time, face to face with the patient, document the progress note properly and provide the required medically necessary components, you deserve to use this code and get paid for your time.
Serious Illness Takes Serious Time
This code can be used for a seriously ill patient in your office, when you are spending a significant amount of time helping, while deciding the best course of action. This would include deciding to admit the patient to the hospital or sending the patient to the emergency room via a 911 call.
Usually, if you are spending over 40 minutes with the patient and have all of the criteria, you are going to document and bill for a 99215. However, if you end up spending any additional time, for example, over another 30 minutes with the patient, and your face-to-face total time counting all other services is 75 minutes or more, you may be entitled to capture the additional CPT code 99354.
Record Your Time!
It is prudent to report the start times and the ending times as well as the face-to-face time, in order to properly capture this code.
Overall, this really is not that difficult. For example, if you have a patient who comes into your office with an exacerbation of their COPD, you may start the patient on oxygen in your office while you perform your History, Physical and Medical Decision Making.
Keep Track of the Intensity of your Care
In the course of this you may order a nebulizer treatment for the patient and then leave the room to see another patient, you should document the time actually spent with the patient up to that point.
Once you return to the room the clock starts again. While speaking with the patient regarding how they feel after the nebulizer treatment, you may decide that they need an injection or another treatment. You document the time and then may have to leave the room to see another patient.
Once you return to the room, the clock starts again; so each time you decide on a treatment option for this patient, you continue to accrue time towards, not only the level CPT 99215 visit as the patient definitely will meet criteria for the intensity and medical necessity, you are potentially capturing the extra time needed to use the CPT 99354 code.
This code will enable you to be able to bill for the extra time you need to spend with the patient while you are stabilizing them, in order to decide if they can return home be transported to the hospital.
Many of us have the occasional patient who will use a significant amount of time in order for you to take proper care of them, to stabilize them and to decide whether the current problem they have can be handled from home or in the hospital.
Code Correctly for your Visit Too
If you provide the care, you deserve the code. That is why it is available in the first place. You owe it to yourself to maximize your revenue. Many providers will only bill this encounter as a CPT 99213 or CPT 99214. The reality is, if you do the work and properly document with the medical necessity in place, you can easily and comfortably bill for the appropriate code CPT 99215 and CPT 99354.
Prolonged Services Definitions
In the office or other outpatient setting, Medicare will pay for prolonged physician services (CPT code 99354) (with direct face-to-face patient contact that requires one hour beyond the usual service), when billed on the same day by the same physician or qualified NPP as the companion evaluation and management codes. The time for usual service refers to the typical/average time units associated with the companion E&M service as noted in the CPT code. You should report each additional 30 minutes of direct face-to-face patient contact following the first hour of prolonged services with CPT code 99355.
In the inpatient setting, Medicare will pay for prolonged physician services (code 99356) (with direct face-to-face patient contact which require one hour beyond the usual service), when billed on the same day by the same physician or qualified NPP as the companion evaluation and management codes. You should report each additional 30 minutes of direct face-to-face patient contact following the first hour of prolonged services may be reported by CPT code 99357.
Required Companion Codes
• Prolonged services codes 99354 – 99357 are not paid unless they are accompanied by the companion codes as described below:
• The companion E&M codes for 99354 are:
• Office or Other Outpatient visit codes (99201 - 99205, 99212 – 99215);
• Office or Other Outpatient Consultation codes (99241 – 99245);
• Domiciliary, Rest Home, or Custodial Care Services codes (99324 – 99328, 99334 – 99337); and
• Home Services codes (99341 - 99345, 99347 – 99350).
• The companion E&M codes for 99355 are 99354 and one of the E&M codes required by 99354.
• The companion E&M codes for 99356 are:
• The Initial Hospital Care and Subsequent Hospital Care codes (99221 - 99223, 99231 – 99233),
• Inpatient Consultation codes (99251 – 99255); and
• Nursing Facility Services codes (99304 -99318).
• The companion codes for 99357 are 99356 and one of the E&M codes required by 99356
Requirement for Physician Presence
You may count only the duration of direct face-to-face contact with 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.
You cannot bill as prolonged services:
• In the office setting, time spent by office staff with the patient, or time the patient remains unaccompanied in the office; or
• In the hospital setting, time spent reviewing charts or discussing the patient with house medical staff and not with direct face-to-face contact with the patient or waiting for test results, for changes in the patient’s condition, for end of a therapy, or for use of facilities.
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, provider should bill the E&M visit code and code 99354. No more than one unit of 99354 is acceptable.
• If the total direct face-to-face time equals or exceeds the threshold time for code 99355 by no more than 29 minutes, provider 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.
• Table 1 (Threshold Time for Prolonged Visit Codes 99354 and/or 99355 Billed with Office/Outpatient and Consultation Codes) on page 5 of MLN Matters article MM5972 displays threshold times the carriers and A/B MACs use to determine if the prolonged services codes 99354 and/or 99355 can be billed with the office or other outpatient settings, including outpatient consultation services and domiciliary, rest home, or custodial care services and home services codes.
• The AMA CPT coding-derived changes are highlighted and noted in bolded italics.
• To get to the threshold time for billing code 99354 and two units of code 99355, providers should add 30 minutes to the threshold time for billing codes 99354 and 99355. For example, when billing code 99205, in order to bill code 99354 and two units of code 99355, the threshold time is 150 minutes.
UnitedHealthcare Community Plan reimburses Prolonged Services with Direct Patient Contact when reported with E/M codes in which time is a factor in determining level of service in accordance with CPT guidelines. Physicians or other qualified health care professionals should report only Prolonged Services with Direct Patient Contact beyond the typical duration of the service on a given date, even if the time spent by the physician or other qualified health care professional is not continuous. Providers should not include the time devoted to performing separately reportable services when determining the amount of prolonged services time. For example, the time devoted to performing cardiopulmonary resuscitation (CPT code 92950) should not be included in prolonged services time. A 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.
* Report CPT code 99354 (office or outpatient place of service codes) for the first hour of prolonged physician or other qualified health care professional services. This code should be used only once per date, and prolonged services must exceed 30 minutes in order to report this service.
* Report CPT code 99355 (office or outpatient place of service codes) for each additional 30 minutes beyond the first 60 minutes of prolonged physician or other qualified health care professional services. Additional services must exceed 15 minutes in order to report this service.
Medicare coverage and Limitation
Low vision services use optical devices and non-optical adaptive equipment, skill training, environmental adaptations and counseling to minimize vision related disability when no restorative process, for example correction of refractive error, corneal transplantation, or cataract surgery is possible.
A Medicare beneficiary with vision loss may be eligible for rehabilitation services designed to improve, restore, and / or compensate for loss of functioning, by therapy, to improve performance of activities of daily living, including self-care and home management skills. Evaluation of the patient's level of functioning in activities of daily living, followed by implementation of a therapeutic plan of care aimed at safe and independent living, is critical. Vision impairment ranging from low vision to total blindness may result from a primary eye diagnosis, such as macular degeneration, retinitis pigmentosa, or glaucoma, or as a condition secondary to another primary diagnosis, such as diabetes mellitus or acquired immune deficiency syndrome (AIDS).
The purpose of rehabilitative therapy is to maximize patients’ independence, safety, quality of life and wellbeing for optimizing the use of residual vision, providing practical skills and adaptations for activities of daily living, providing the skills and resources for community participation, and modifying environments to assure safety. Rehabilitation appears to be more effective if it is started as soon as functional visual difficulties are identified.
The level of vision impairment is defined as:
1. Moderate: best corrected visual acuity is less than 20/60
2. Severe (legal blindness) best corrected visual acuity is less than 20/160, or visual field is 20 degrees or less
3. Profound (moderate blindness) best corrected visual acuity is less than 20/400, or visual field is 10 degrees or less
4. Near-total (severe blindness) best corrected visual acuity is less than 20/1000, or visual field is 5 degrees or less
5. Total (total blindness) no light perception.
Loss of central area of detail with macular degeneration, resulting in distortion, (a) and missing segments of words. (b) Magnification of reading material may allow a patient to read.
Indications for Low Vision Service
The criteria for a low vision evaluation (L/VE) by a physician is self-reported functional deficit secondary to any level of visual impairment that cannot be resolved by standard glasses, medicine or surgery.
The criteria for rehabilitation therapy for low vision are met when any of the following categories are fulfilled, and functional deficit compromising daily activities has been confirmed and delineated by a low vision evaluation:
1. 369.00-369.25: Impairment of central visual acuity remaining vision in the better eye after best correction is documented at less than 20/60.
2. 368.41: A central scotoma is demonstrated.
3. A visual field reduction is demonstrated, including 368.45 (generalized constriction), 368.46 (homonymous bilateral field constriction), or 368.47 (heteronymous bilateral field constriction).
When a comprehensive low vision evaluation by a physician that confirms and delineates functional deficits compromising daily activities is not available and provided, a score of 70 on the Visual Function Questionnaire (VFQ) is required for rehabilitation therapy.
The VFQ-25 survey developed by Rand under the sponsorship of the National Eye Institute is an instrument to measure both health related quality of life (HRQOL) and visual function. It is useful in establishing the provider, patient relationship, a treatment plan and identifying goals. Expectations and achievable goals must be explicitly stated based upon responses to concrete questions like those in the VFQ-25 or the following:
Can you apply make-up or shave?
Do you see well enough to use public transportation?
Can you identify denominations of money or sign a check?
Are you visually able to read price tags, labels or large print books?
If the patient lives confidently with their current visual function visual rehabilitation is not medically necessary. Patients without a perceived need to improve their visual function will not be motivated to learn and practice the complex functions necessary for low vision training. Patients with cognitive impairments that impeded their retention are at an even higher risk for falls and injuries, however, and are likely to benefit from environmental adaptations and caregiver training to insure their safety. Occupational therapists are trained to observe for and manage cognitive deficits and they work under established regulations that dictate that when no progress is made in two consecutive visits, for any reason, therapy must be terminated.
Not all of those reporting a visual disability have a permanent or uncorrectable visual impairment. One purpose of the policy is to establish eligibility criteria for low vision services. A second goal is to define minimum documentation guidelines which will enable a reviewer to determine if goals are relevant to perceived needs of the patient. In addition the policy seeks bright-line determinants of when goals have been achieved or progress has reached a plateau, and treatment is maintenance, which is non-covered by Medicare begins.
Providers of Service
A team usually performs low vision services. The responsible physician may be one who diagnoses and treats the disease or may be one who performs the comprehensive low vision evaluation (LVE). In either case, the physician is the treatment planner and manager. Qualified assistants may assist the physician in collecting information such as medical history and performing visual field testing. Rehabilitation therapy to implement the vision rehabilitation plan is provided by occupational therapists.
Incident to provisions apply only when those who assist the managing physician are employees defined in the Medicare Benefit Policy Manual, (Pub.100-2, Chapter 15, §60) and fulfill all the “incident to” requirements. Incident to services are integral but incidental to the physician's services. This may include history taking as part of the low vision evaluation and performance of peripheral and central visual field testing. Non-occupational therapists may not conduct rehabilitation therapy and any services they provide may not be billed under occupational therapy codes.
A non-occupational therapist, serving in any capacity incident to a physician must be directly supervised by that physician. For example, a certified technician may not go to a patient’s home to collect data incident to a physician unless the physician is there in the residence with the technician.