Sunday, April 8, 2012

cpt codes 99354 - 99357, 99355, 99356

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)


UnitedHealthcare Community Plan reimburses Prolonged Services 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 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.

* Report CPT code 99356 (inpatient or observation place of service code) 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 99357 (inpatient or observation place of service code) 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.

* Report CPT code 99358 (office, outpatient, inpatient or observation 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 99359 (office, outpatient, inpatient or observation 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.

* Report CPT code 99415 (office or outpatient place of service codes) for the first hour of prolonged clinical staff services of direct patient contact with physician supervision. 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 99416 (office or outpatient place of service codes) for each additional 30 minutes beyond the first 60 minutes of prolonged clinical staff services of direct patient contact with physician supervision. Additional services must exceed 15 minutes in order to report this service.

According to CPT, prolonged service codes 99354-99357, 99359, and 99415-99416 are considered addon codes and should not be reported without the appropriate primary code. Refer to UnitedHealthcare Community Plan’s “Add-on Policy” for details. Prolonged services for labor and delivery are not separately reimbursable services. As described in American Congress of Obstetricians and Gynecologists (ACOG) coding guidelines, prolonged services are not reported for services that do not have a time component such as labor and delivery management. Refer to UnitedHealthcare Community Plan’s "Obstetrical Policy" for more information.

In accordance with The Centers for Medicare and Medicaid Services (CMS), Prolonged Services without Direct Patient Contact (CPT codes 99358-99359) will not be separately reimbursed when reported with CCM CPT codes 99487 and 99489 and TCM CPT codes 99495 and 99496.

Questions and Answers

Q: Do Prolonged Services with Direct Patient Contact include patient time spent with office staff and/or patient time spent unaccompanied in the office?

A: No. The Prolonged Services with Direct Patient Contact must be between the patient and the physician or other qualified health care professional who provided the initial service. Office staff includes anyone who is not the primary provider of the service. The time a patient remains unaccompanied by the primary provider also cannot be counted.


Q: Is time spent waiting for test results or for potential changes in a patient's condition reported as prolonged services ?

A: Per CMS, time spent waiting for test results or for changes in the patient's condition cannot be reported as prolonged services.

Q: Should a physician or other qualified health care professional report prolonged services with preventive medicine E/M codes (CPT codes 99381-99397)?

A: No. Preventive medicine codes are not time-based codes; therefore, prolonged services are not separately reimbursed.


Q: May a physician or other qualified health care professional report prolonged services (CPT codes 99354-99357) with modifier 25 when a significant and separately identifiable E/M service is performed along with a separate service or procedure?

A: According to CPT, modifier 25 may be appended to prolonged services codes if there is adequate supporting documentation that describes the service provided and indicates the service is significant and separately identifiable from another service or procedure on the same date of service.



Prolonged Services and Standby Services (Codes 99354 - 99360)

Prolonged Services With Direct Face-to-Face Patient Contact Service (ZZZ codes)

A.Definition

Prolonged physician services (CPT code 99354) in the office or other outpatient setting with direct face-to-face patient contact which require 1 hour beyond the usual service are payable when billed on the same day by the same physician or qualified nonphysician practitioner (NPP) as the companion evaluation and management codes. The time for usual service refers to the typical/average time units associated with the companion evaluation and management service as noted in the CPT code. Each additional 30 minutes of direct face-to-face patient contact following the first hour of prolonged services may be reported by CPT code 99355.

Prolonged physician services (code 99356) in the inpatient setting, with direct face-to- face patient contact which require 1 hour beyond the usual service are payable when they are billed on the same day by the same physician or qualified NPP as the companion evaluation and management codes. 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.

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 may be used to report each additional 30 minutes beyond the first hour of prolonged services, based on the place of service. These codes may be used to report the final 15 – 30 minutes of prolonged service on a given date, if not otherwise billed. 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.

B.Required Companion Codes

The companion evaluation and management codes for 99354 are the Office or Other Outpatient visit codes (99201 - 99205, 99212 – 99215), the Domiciliary, Rest Home, or Custodial Care Services codes (99324 – 99328, 99334 – 99337), the Home Services
codes (99341 - 99345, 99347 – 99350);

The companion codes for 99355 are 99354 and one of the evaluation and management codes required for 99354 to be used;

The companion evaluation and management codes for 99356 are the Initial Hospital Care codes and Subsequent Hospital Care codes (99221 - 99223, 99231 – 99233); Nursing
Facility Services codes (99304 -99318); or

The companion codes for 99357 are 99356 and one of the evaluation and management codes required for 99356 to be used.

Prolonged services codes 99354 – 99357 are not paid unless they are accompanied by the companion codes as indicated.

C.Requirement for Physician Presence

Physicians may count only the duration of direct face-to-face contact between the physician and 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. In the case of prolonged office services, time spent by office staff with the patient, or time the patient remains unaccompanied in the office cannot be billed. In the case of prolonged hospital services, time spent reviewing charts or discussion of a 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 cannot be billed as prolonged services.

D.Documentation

Documentation is not required to accompany the bill for prolonged services unless the physician has been selected for medical review. Documentation is required in the medical record about the duration and content of the medically necessary evaluation and management service and prolonged services billed. The medical record must be appropriately and sufficiently documented by the physician or qualified NPP to show that the physician or qualified NPP personally furnished the direct face-to-face time with the patient specified in the CPT code definitions. The start and end times of the visit shall be documented in the medical record along with the date of service.

E.Use of the Codes

Prolonged services codes can be billed only if the total duration of the 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.


F.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. 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. Contractors use the following threshold times 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

Code Typical Time
for Code Threshold Time
to Bill Code Threshold Time
to Bill Codes
99354 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
99324 20 50 95
99325 30 60 105
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

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.

G.Threshold Times for Codes 99356 and 99357

(Inpatient Setting) If the total direct face-to-face time equals or exceeds the threshold time for code 99356, but is less than the threshold time for code 99357, the physician should bill the visit and code 99356. Contractors do not accept more than one unit of code 99356. If the total direct face-to-face time equals or exceeds the threshold time for code 99356 by no more than 29 minutes, the physician bills the visit code 99356 and one unit of code 99357. One additional unit of code 99357 is billed for each additional increment of 30 minutes extended duration. Contractors use the following threshold times to determine if the prolonged services codes 99356 and/or 99357 can be billed with the inpatient setting codes.

Threshold Time for Prolonged Visit Codes 99356 and/or 99357 Billed with Inpatient Setting Codes

Code Typical Time for Code Threshold Time to Bill Threshold Time to Bill
Code 99356 Codes 99356 and 99357
99221 30 60 105
99222 50 80 125
99223 70 100 145
99231 15 45 90
99232 25 55 100

Add 30 minutes to the threshold time for billing codes 99356 and 99357 to get the threshold time for billing code 99356 and two units of 99357.

H.Prolonged Services Associated With Evaluation and Management Services Based on Counseling and/or Coordination of Care (Time-Based)

When an evaluation and management service is dominated by counseling and/or coordination of care (the counseling and/or coordination of care represents more than 50% of the total time with the patient) in a face-to-face encounter between the physician or qualified NPP and the patient in the office/clinic or the floor time (in the scenario of an inpatient service), then the evaluation and management code is selected based on the typical/average time associated with the code levels. The time approximation must meet or exceed the specific CPT code billed (determined by the typical/average time associated with the evaluation and management code) and should not be “rounded” to the next higher level.

In those evaluation and management services in which the code level is selected based on time, prolonged services may only be reported with the highest code level in that family of codes as the companion code.

I.Examples of Billable Prolonged Services EXAMPLE 1

A physician performed a visit that met the definition of an office visit code 99213 and the total duration of the direct face-to-face services (including the visit) was 65 minutes. The physician bills 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 code 99327 and the total duration of the direct face-to-face contact (including the visit) was 140 minutes. The physician bills 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 should report CPT code 99215 and one unit of code 99354.

J.Examples of Nonbillable 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-to-face 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.

Prolonged Services Without Direct Face-to-Face Patient Contact Service (Codes 99358 - 99359)


Contractors may not pay prolonged services codes 99358 and 99359, which do not require any direct patient face-to-face contact (e.g., telephone calls). Payment for these services is included in the payment for direct face-to-face services that physicians bill. The physician cannot bill the patient for these services since they are Medicare covered services and payment is included in the payment for other billable services.


2 comments:

  1. Most developed in wealthy countries, where it has become a major channel of saving and investing.
    Health Insurance Australia

    ReplyDelete
  2. HOW WOULD YOU BILL 90837 WITH THE 99354 AND 99355 OUR PATIENT WAS SEEN FOR 3 HRS AND THEN FOR 4 HRS

    ReplyDelete

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