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Comprehensive Error Rate Testing

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Prolonged Services

Insufficient documentation causes most improper payments. Insufficient documentation means that something was missing from the medical records. Below is a list of the most common reasons CERT determined there was insufficient documentation that caused improper payments for prolonged services with face-to-face contact.

  • Start and stop time was not documented
  • The prolonged service was not billed on the same claim as the companion code
  • The prolonged service does not meet the threshold time
  • Missing electronic signature or legible signature of the performing provider

Start and stop time: The start and end times of the visit shall be documented in the medical record along with the date of service.

Not billed with companion code: The prolonged service codes 99354–99357 must be billed with the appropriate companion code on the same claim. If the companion code is billed on a separate claim, CERT cannot review that other claim to determine if the prolonged service should be allowed.

Does not meet the threshold time: 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.

Signature: An electronic signature or legible signature is required on medical records.

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