Prolonged Services  CPT CODE AND Description


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





99355 Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (List separately in addition to code for prolonged service)

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.


99415  Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour (List separately in addition to code for outpatient Evaluation and Management service)

99416  Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; each additional 30 minutes (List separately in addition to code for prolonged service)

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 30minutes of direct face-to-face patient contact following the first hour of prolonged services may be reported by CPT code 99357.

Required Companion Codes

Please remember that prolonged services codes 99354 – 99357 are not paid unless they are accompanied by the companion codes as described here.

The companion E&M codes for 99354 are:

* Office or Other Outpatient visit codes (99201 – 99205, 99211 – 99215),
* Office or Other Outpatient Consultation codes (99241 – 99245),
* Domiciliary, Rest Home, or Custodial Care Services codes (99324 – 99328, 99334 – 99337),
* Home Services codes (99341 – 99345, 99347 – 99350);

The companion E&M codes for 99355 are 99354 and one of its required E&M codes.

The companion E&M codes for 99356 are the Initial Hospital Care and Subsequent Hospital Care codes (99221 – 99223, 99231 – 99233), the Inpatient Consultation codes (99251 – 99255); Nursing Facility Services codes (99304 -99318).

The companion codes for 99357 are 99356 and one of its required E&M codes.

Use of the Codes

You can only bill the prolonged services codes 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).

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, you 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, you 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 displays threshold times that your 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

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

Code Typical Time for Code Threshold Time to Bill Code 99354

Threshold Time to Bill Codes 99354 and 99355

99201 10 40 85
99202 20 50 95
99203 30 60 105
99204 45 75 120
99205 60 90 135
99212 10 40 85
99213 15 45 90
99214 25 55 100
99215 40 70 115
99241 15 45 90
99242 30 60 105
99243 40 70 115
99244 60 90 135
99245 80 110 155
99324 20 50 95
99326 45 75 120
99327 60 90 135
99328 75 105 150
99334 15 45 90
99335 25 55 100
99336 40 70 115
99337 60 90 135
99341 20 50 95
99342 30 60 105
99343 45 75 120
99344 60 90 135
99345 75 105 150
99347 15 45 90
99348 25 55 100
99349 40 70 115
99350 60 90 135

To get to the threshold time for billing code 99354 and two units of code 99355, 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.

Billing Examples Examples of billable and non-billable prolonged services follow.

* Billable Prolonged Services

EXAMPLE 1 

A physician performed a visit that met the definition of an office visit CPT code 99213 and the total duration of the direct face-to-face services (including the visit) was 65 minutes. The physician bills CPT code 99213 and one unit of code 99354.

EXAMPLE 2

A physician performed a visit that met the definition of a domiciliary, rest home care visit CPT code 99327 and the total duration of the direct face-to-face contact (including the visit) was 140 minutes. The physician bills CPT codes 99327, 99354, and one unit of code 99355.

EXAMPLE 3

A physician performed an office visit to an established patient that was predominantly counseling, spending 75 minutes (direct face-to-face) with the patient. The physician bills CPT code 99215 and one unit of code 99354.

* Non-billable Prolonged Services

EXAMPLE 1

A physician performed a visit that met the definition of visit code 99212 and the total duration of the direct face-to-face contact (including the visit) was 35 minutes. The physician cannot bill prolonged services because the total duration of direct face-toface service did not meet the threshold time for billing prolonged services.

EXAMPLE 2 

A physician performed a visit that met the definition of code 99213 and, while the patient was in the office receiving treatment for 4 hours, the total duration of the direct face-to-face service of the physician was 40 minutes. The physician cannot bill prolonged services because the total duration of direct face-to-face service did not meet the threshold time for billing prolonged services.


EXAMPLE 3

A physician provided a subsequent office visit that was predominantly counseling, spending 60 minutes (face-to-face) with the patient. The physician cannot code 99214, which has a typical time of 25 minutes, and one unit of code 99354. The physician must bill the highest level code in the code family (99215 which has 40 minutes typical/average time units associated with it). The additional time spent beyond this code is 20 minutes and does not meet the threshold time for billing prolonged services.

Finally, you should remember that Medicare contractors will not pay (nor can you bill  the patient) for prolonged services codes 99358 and 99359, which do not require any direct patient face-to-face contact (e.g., telephone calls). These are Medicare covered services and payment is included in the payment for other billable services.

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.

Payment  Guidelines

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.