decisionhealth Newsletters, Answer Books - 2008 Issue 5 (May)
Medicare_Carriers_Manual / 15511 / 15511
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Article Overview
This article explains Medicare policy for prolonged physician services and how those services relate to evaluation and management visits. It covers companion code requirements, physician presence and documentation expectations, threshold-time tables for multiple visit categories, and examples of billable and nonbillable scenarios. The material is aimed at coders, billers, and physicians who need to understand when prolonged services guidance applies and what general documentation is expected.
Why This Topic Matters
Prolonged services billing depends on time, visit context, and documentation, so misunderstandings can lead to claim denials or improper payment. This guidance helps readers recognize the policy framework and the categories of visit codes tied to prolonged service reporting.
Article Sections
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A. Required Companion Codes
Explains the general requirement for companion evaluation and management visit categories associated with prolonged services reporting.
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B. Requirement for Physician Presence
Discusses how physician time is counted for prolonged services and what kinds of time are excluded from consideration.
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C. Documentation
Addresses documentation expectations for prolonged services and when supporting records may be requested.
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D. Use of the Codes
Summarizes the relationship between total face-to-face time and the general availability of prolonged services reporting.
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E. Threshold Times for Codes 99354 and 99355
Presents time thresholds for prolonged services tied to office, outpatient, and consultation visit categories.
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F. Threshold Times for Codes 99356 and 99357
Presents time thresholds for prolonged services tied to additional inpatient and related visit categories.
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G. Examples of Billable Prolonged Services
Provides sample scenarios illustrating when prolonged services reporting is permitted under the policy framework.
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H. Examples of Nonbillable Prolonged Services
Provides sample scenarios illustrating when prolonged services reporting is not available under the policy framework.
What You Will Learn
- How Medicare frames prolonged physician services within evaluation and management billing
- Which broad categories of companion visits are discussed in the policy
- What types of physician time are considered for prolonged services guidance
- What documentation themes are associated with supporting prolonged services reporting
- How threshold-time tables are organized for different visit categories
- How the article distinguishes general billable and nonbillable prolonged services scenarios
Who Should Read This
- Medical coders
- Billing staff
- Physicians
- Compliance personnel
- Revenue cycle teams
Codes Discussed
Code Ranges Discussed
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