Have you ever had a patient take more time with the provider than they were scheduled for? Do you understand which codes to report and the rules that govern them to allow for better reimbursement? Prolonged Service codes were created just for that reason but you must carefully follow the documentation and coding guidelines to avoid problems. These “add-on” codes are reportable only when an Evaluation and Management code has been reported as the primary code. There are three types of Prolonged Service codes (see below) but here we will review the rules pertaining to codes 99354-99357.
There are three sets of codes for reporting various types of prolonged E/M services:
CPT codes for Prolonged Service with Direct Patient Contact (99354-99357) include the following subcategories:
Office/Other Outpatient Setting (direct face-to-face services)
99354 First hour
99355 Each additional 30 minutes beyond the first hour
Inpatient Setting (direct face-to-face services)
99356 First hour
99357 Each additional 30 minutes beyond the first hour
Prolonged Service Codes Are Add-On Codes
All of these codes are considered “add-on” codes and should only be reported after a primary Evaluation and Management service code has been reported. Time and Direct face-to-face contact are the two main criteria for determining whether one or both codes are reported. Documentation must identify the total time (start and stop times are preferred by payers) spent in direct, face-to-face contact with the patient (either continuous or accumulated) as well as what was discussed, counseled, or coordinated with the patient. If time is accumulated, then documentation of what the patient was being monitored for (by the provider) should be documented in the medical record.
Rule of Halves
The rule of halves is applicable to specific timed codes. It indicates that as long as half (or more) of the assigned time is achieved, the code can be reported. For example, to qualify for 99354 (which has an assigned time of 60 minutes), the provider only has to complete the first 30 minutes. Anything less than 30 minutes doesn’t qualify. However, the second add-on code 99355 (which has an assigned time of 30 minutes), requires the full 60 minutes of the first code to be completed followed by an additional 15 minutes to reach the halfway mark for code 99355.
Direct Face-to-Face Defined
Direct face-to-face is defined by the American Medical Association vaguely for office/outpatient as face-to-face contact with the physician or other qualified healthcare professional and in the hospital or nursing facility as “includes additional non-face-to-face services on the patient’s floor or unit in the hospital or nursing facility during the same session.” However, Medicare is far more deliberate in their definition:
Office/Other Outpatient: The Medicare Claims Processing Manual 188.8.131.52.C states, “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.”
Hospital Inpatient or Nursing Facility: The Medicare Claims Processing Manual 184.108.40.206.C states, “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 counted as direct, face-to-face time.”
A total time should be calculated with start and stop times (especially if the payer specifies they are required). In the case of accumulated time (where face-to-face time is not continuous) the provider should document a total face-to-face time in the medical record. A total time (including start and stop times) should be documented in the medical record for patients receiving prolonged evaluation and management services in the Office or Other Outpatient setting.
TIP: Time-based E/M services must identify what the patient was counseled on or about or what was coordinated. It does not have to be detailed, but must be sufficient enough to stand up in a court setting. Simply summarize (with enough detail to make it individual to the patient) what was discussed or done during that time.
A very generic statement, such as, “A total of 75 minutes was spent counseling and coordinating care for the patient” would not suffice. The note should identify what was counseled, discussed, coordinated, or monitored that required the provider’s presence and services. It does not have to be detailed, but the rule of thumb should be to provide enough information that three (3) years later a provider could look at the note and defend it.
Putting It All Together
When the provider has documented time spent face-to-face with the patient that goes above and beyond the “norm,” he/she may review the service to see if it qualifies for prolonged evaluation and management service codes.
The encounter must first be scored (either by time or key components) and coded with an appropriate E/M service code. If based on components, it means the documentation requirements for history, exam, and medical decision making have determined the level of E/M service. If based on time, it means the highest level of E/M service (new or established; initial or subsequent) has been selected.
Once an E/M code has been assigned, identify the typical time associated with that code and deduct it from the total time spent face-to-face with the patient.
1. In the office setting, the E/M service, based on component coding, was 99213, which carries a typical time of 15 minutes. The total face-to-face time spent with the patient was 60 minutes. Deduct the 15 minutes from the total time of 60 minutes, which leaves 45 minutes remaining. This is the time used to determine whether or not the service qualifies for Prolonged Services.
2. In the facility setting, an initial patient’s E/M service based on time, was noted to qualify for 99223, which carries a typical time of 70 minutes. The total face-to-face time documented in the record was 92 minutes. Deduct the 70 minutes from the 92 minutes, which leaves 22 minutes remaining. This is the time used to determine whether or not the service qualifies for Prolonged Services.
Determine if the time remaining qualifies for application of the first Prolonged Service code. Using the above examples, we’ve determined the following:
After deducting the E/M service time from the total time, 45 minutes remained. Because more than half of the 60-minute time requirement was achieved, the service qualifies for 1 unit of Prolonged Service 99354.
2. After deducting the E/M service time from the total time, 22 minutes remained. Because at
least half of the 60-minute time requirement was not achieved, it does not qualify for a
Prolonged Service code. This extra 22 minutes would simply be considered included in the
initial E/M service.
After the first Prolonged Service code has been achieved, determine if there is additional time that may be considered towards an add-on code (99355, 99357) as well. Using the examples above, we’ve determined the following:
An example in which the second add-on code would qualify would be as follows:
An established patient returned to our office for a refill of pain medications and to discuss the pathology and imaging findings related to her recently diagnosed malignant neoplasm of the left breast. A total of 148 minutes were spent, face-to-face, counseling the patient regarding her prognosis, surgical and nonsurgical options, risks, complications, alternatives, and recommended oncologists. Based on face-to-face time alone, the following codes would be reported:
99215 (40 minutes)
99354 (60 minutes)
99355 (30 minutes)
99355* (18 minutes)
*(The 99355 would simply be reported with two (2) units)
Coding Based on Accumulated Time (not continuous)
An 8-year-old boy, established patient, presented to our office for an allergic reaction to a wasp sting of the right temple yesterday at noon. His mother reports giving him 25 mg of Benadryl within 10 minutes of the sting and washing the sting site with warm soapy water. She reports no symptoms until this morning, when he awoke with severe facial swelling indicating a delayed but possibly severe allergic reaction.
The provider documents a level of service to include detailed history and examination as well as a moderate complexity decision making. It was decided to administer an injection of adrenaline and monitor the patient. Additional treatment of Benadryl and antibiotics were administered as well. The provider was in and out of the patient room monitoring the patient and discussing findings with the mother. Total face-to-face time was 70 minutes.
Coding: The provider reported 99214 and 99354. There was not enough time to qualify for 99355.
Sometimes using a Time Table makes identifying eligible services easier. The table identifies the E/M service type and level with the typical time and the last two columns identify the time required to report a single unit of each add-on code.
Prolonged Evaluation and Management Service Threshold Times
Typical Time for E/M
Threshold Time 99354 or
Threshold Time to add 99355 or
Aimee Wilcox, MA, CST, CCS-P is a Certified Coding Guru (CCG) for Find-A-Code. For more information about ICD-10-CM, ICD-10-PCS, and medical coding and billing please visit FindACode.com where you will find the ICD-10 code sets and the current ICD-9-CM, CPT, and HCPCS code sets plus a wealth of additional information related to medical billing and coding.
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innoviHealth Systems, Inc.
62 East 300 North
Spanish Fork, UT 84660
Phone: 801-770-4203 (9-5 Mountain)