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Viewing:  Dec 9, 2016

Prolonged Evaluation and Management (EM) Services (99354, 99355)

By Aimee Wilcox, MA, CST, CCS-P

Have you ever had a patient take more time with the doctor than they were scheduled for? Do you think that visit should be reimbursed at a higher rate than normal? Well, prolonged time spent with a patient is reimbursable but you have to know how to capture those charges and what to document in the patient's chart to qualify for the additional money.

The CPT manual provides Prolonged Service with Face-To-Face Contact codes 99354, 99355 for situations just like this. Specific criteria must be met to report these codes, so let's take a look at how to do that correctly.

Code and Description:

99354 Prolonged Service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient EM service)

99355 Prolonged service 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 office or other outpatient EM service)

When a patient is seen in the office or other outpatient setting for an EM service, the provider must determine if the service level is based on one of two things:

  1. Level of Service: Documentation supporting criteria for the EM service in history, physical examination and medical decision making.
  2. Time: Documented time spent face-to-face with the patient with the majority of the time (50% or greater) spent in counseling and/or coordination of care.

The proper use of prolonged service codes are also based on this decision. Let's review an example for each.

Level of Service:  Criteria for level of EM service + time.

Example 1:

An 8-year-old boy was seen in the office today for facial swelling from a wasp sting he sustained on the right temple at noon yesterday. His mother reports giving him 25 mg of Benadryl within 10 minutes of the sting and reports no symptoms until this morning when he awoke with severe facial swelling indicating a delayed severe allergic reaction The provider documents a level of service to include detailed history, detailed PE and MDM of moderate complexity. 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 with a total amount of time spent in face-to-face contact of 70 minutes (including time spent on the examination).

In this scenario, the provider based the documentation on the level of service and not on time alone.

Documentation of level of service supports 99214, which carries a time of 25 minutes. To properly report prolonged service time, subtract the 25 minutes from the total time spent face-to-face with the patient. This leaves 45 minutes of the provider's time that needs to be paid for.

Prolonged service code 99354 is reported when the provider spends 30-74 minutes (beyond the EM service time) in face-to-face contact with the patient. The report shows that the prolonged time is 45 minutes, which falls within this code description. The appropriate codes to report include 99214 and 99354.

Reporting the prolonged service code in addition to the EM code, the provider will be reimbursed approximately $95 more for this service then if he had just billed for the EM code 99214.

When the visit extends beyond the 74 minutes, an add-on code (99355) is reported. This code is used when the service extends from 75 minutes to 90 minutes and according to the Medicare fee schedule, is worth about $93.

For each additional 15 minutes beyond the 90 minutes, you can apply another unit of 99355.

To illustrate, if the provider had spent a total of 105 minutes with the patient above, the services billed would include 99214 (25 minutes), 99354 (30-74 minutes), and 99355 (75-90 minutes).

Time:  Based solely on time (50% or greater) spent on counseling/coordination of care.

When the EM service is based on time, the majority of the time spent with the patient must be spent in counseling or coordination of care.

Documentation may still show all, some, or none of the history, physical examination or medical decision making but time must be documented clearly.

Example 2:

This established patient presented for pain management service. Chronic pain management including induction from MSContin to suboxone was discussed. The risks, complications and alternatives of the induction were discussed with the patient and all of his questions were answered. We reviewed the risks associated with suboxone use, overuse, and management in detail. Additionally, we reviewed his lumbar MRI, which revealed facet arthritis of the L3-S1 levels. The patient will be scheduled for medial branch blocks of the L3-S1 followed by RF of these same levels if positive result from the MBB is noted. We discussed the risks, complications, and alternatives of both procedures and answered all his questions. I spent approximately 70 minutes with the patient with the majority of the time spent in counseling.

In this scenario, the EM code would be based on time and should be taken from the highest level of service within the qualifying EM category. Established patient, office, 99215 (40 minutes).

After deducting the 40 minute time associated with 99215 from the total time, you can see that the 30 minutes remaining does qualify for 99354.

Final code selection: 99215, 99354.

If the provider had spent 78 minutes with the patient, then the time beyond the EM code (40 minutes) and 99354 (60 minutes) would be an additional 18 minutes. Although it doesn't equal the 30 minutes for code 99355, once you have hit the 15 minute mark (half the time) you can go ahead and report 99355 also. However, in order to report another 99355 you would have to complete the 30 minutes for this first one and then an additional 15 minutes into the next.

This time criteria can be tricky so let's see if we can make is easier to understand by using the chart below, which breaks down the time associated with the EM code and threshold times associated with 99354 and 99355

Code Typical Time
for Code
Threshold Time
to Bill 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
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

If you do not grasp this concept, you may be losing money for your provider or overcharging the insurance company so review this information carefully before attempting to report these codes for additional reimbursement.

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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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