Sunday, April 8, 2012

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)


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.

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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