Skip to Main Content
 
 
 
Web Content Viewer

Policy Education Topics

Web Content Viewer
Web Content Viewer

Prolonged Services

  1. Can time spent over the course of two or more days be aggregated to count toward time requirements for non-F2F service?

    Answer:
    Time spent in performance of non-F2F service(s) may only be aggregated over a single date of service. If time spent on a single day is not sufficient to meet the time requirement, then the service cannot be billed. Added 4/12/2018

  2. Please clarify the use of the non-F2F prolonged service codes (99358-99359) in relation to discharge services (99238-99239).

    Answer:
    Discharge services (99238-99239) are not billable with the inpatient F2F prolonged service codes (99356-99357), since 99239 describes “more than 30 minutes” of time spent in discharge activities. The discharge codes (99238-99239) are intended to include all such services on the date of discharge.

    It may be appropriate to bill the non-F2F prolonged service codes (99358-99359) for medically necessary services beyond the date of discharge and relative to the discharge services. Example: Two days post-discharge, a provider spends 45 minutes of telephone time with the patient and/or a family member representing the patient. Such time is billable as non-F2F prolonged service, and should be documented as relative to the prior discharge service two days before. Added 11/30/2017

  3. Can a mid-level (NPP or APRN-CNP) of the same group practice/specialty perform the non FTF service while the physician performs the FTF office visit?

    Answer:
    CMS’s phrasing “to report extended qualifying time of the billing physician or other practitioner (not clinical staff)” is interpreted by NGS as follows: the non FTF prolonged service codes are intended for use by the individual provider who renders the associated service and who will be billing the service, whether that individual is in a solo or group practice. The provider may be a physician or NPP. As such, these codes cannot be added to a related service as representative of time spent by anyone other than the rendering/billing provider, and this exclusion applies to other clinical office staff. The time spent by the rendering/billing provider must meet or exceed 31 minutes in excess of the suggested time for the related FTF service.

    There are several reasons that the scenario posed by this question is not supportive of prolonged service:
    1. Time spent by a group member other than the rendering/billing provider does not count toward non FTF prolonged service.
    2. Time spent in the posed scenario is simultaneous, not in excess of the associated service.
    3. Non FTF time may represent extensive medical record review, or extensive time spent in telephone discussions or family meetings without patient participation. The information obtained or shared must be essential to the rendering/billing provider in patient management; time spent by another group member is not considered medically necessary to the patient’s management. Added 10/5/2017
       
  4. Can you bill an E&M visit for family meetings when the patient is not present?

    Answer:
    Family meetings without the patient’s presence may be billed using the non face-to-face prolonged service codes (CPT codes 99358-99359), which were implemented by CMS on 1/1/2017. The meeting must be medically necessary relative to the patient’s condition.

    The service may be billed on the same DOS as a face-to-face visit, or may be billed for a DOS before or after a related encounter. The medical record entry must demonstrate the actual DOS and exact time spent in the meeting, along with general commentary on the meeting focus issues; the record must also reflect the date of the face-to-face service to which the meeting is related. Updated 8/29/2017
     
  5. A provider performs a 99233 on one DOS, followed by additional non face-to-face time on a subsequent date, reviewing the patient’s prior medical records and discussing the patient’s status with the patient’s family. Is the subsequent non-face-to-face time billable to Medicare?

    Answer:
    Non face-to-face time (31 or more minutes) spent before or after a related face-to-face service may be billable with CPT codes 99358-99359. Updated 8/29/2017
     
  6. Please clarify the use of a non F2F prolonged service, for extensive review of a prospective patient’s medical record, when the patient fails to appear for the scheduled appointment.

    Answer:
    Review of extensive medical records is billable as a non F2F prolonged service when it exceeds 30 minutes beyond the suggested time for the associated F2F service. The service is not billable unless an associated F2F encounter occurs. Updated 8/29/2017
     
  7. Does time spent filling out a patient’s disability forms meet the criteria for billing a non F2F prolonged service?

    Answer:
    Time spent filling out forms is not billable as non F2F prolonged service. Updated 8/29/2017
     
  8. Does time spent on the phone with the patient’s insurance company obtaining a prior authorization for a patient meet the criteria for billing this service?

    Answer:
    Time spent on the phone for insurance authorization is not billable as non F2F service. As a reminder, these services are only payable for actual time spent by the billing provider, not for office staff time. Updated 8/29/2017
     
  9. Please clarify performance of non-F2F office service by a PCP, subsequent to an associated base hospital visit by a hospitalist.

    Answer:
    A non-F2F prolonged service can only be billed in association with a prior or subsequent base E&M by the same performing/billing provider. To meet the billing criteria, the non-F2F time must equal or exceed 31 minutes beyond the average time of the associated base code. The base code and the non-F2F code may occur in different POS, but must be performed by the same individual provider. Updated 8/29/2017
     
  10. Is there a documentation requirement when billing for prolonged services in the hospital? Is the statement “>30 minutes spent” adequate for documenting prolonged service?

    Answer:
    Documentation for prolonged services must clearly describe the reasons for the prolonged time and the general content of care and/or discussion that took place during both the base code and the prolonged, extended timeframe. Updated 6/9/2017
     
  11. In a hospitalist group, can face to face prolonged care be calculated as provided by several group members on a single date of service?

    Answer:
    Yes, same-specialty hospitalists working within a group may combine cumulative time over a 24 hour period to reflect prolonged service time. Updated 6/9/2017
     
  12. If two hospitalist providers (same group/ same specialty) see a patient on the same day, can both E&M services be combined to represent a higher level of E&M service? Does this also apply to prolonged services?

    Answer:
    If the combined services by same specialty provider within a group meet the level of care described by the higher level service, the service may be billed using the higher code. When the cumulative time spent by these providers meets the level of prolonged service, it may be appropriate to add a prolonged service code(s) to the base E&M. Updated 6/9/2017
     
  13. CMS states that only the E&M rendering provider can bill a prolonged service on the same day. How does this apply to same specialty provider groups?

    Answer:
    Providers within a same-specialty group are considered as a single entity and services by multiple group members over a given day may be combined. If that combined time meets the standards for prolonged care, it may be appropriate to add a prolonged service code to the base E&M code. Updated 6/9/2017
     
  14. An inpatient is seen by one group member early in the day for 25 minutes and the visit is coded as CPT code 99232. Later that same day, the patient is seen by another provider in the same group for 40 minutes, for a worsening condition. Would this situation be appropriate for billing prolonged service, since the total time spent (65 minutes) exceeds the suggested time for CPT code 99232 (25 minutes) by more than 30 minutes?

    Answer:
    Cumulative time spent by same-specialty physician group members over the course of a given day can be aggregated toward addition of a prolonged service code when appropriate, and billed with the rendering code of the base-service provider. This concept does not apply to group members who are NPPs, since they are not of the same specialty as physician group members. An NPP may add a prolonged service code to a base E&M service for which he/she, or a same-specialty group member, was the rendering provider, when all other guidelines described here are met. Updated 6/9/2017

  15. In a scenario where a shared visit between an attending and an NP (part of the practice plan) is performed and then in addition, the NP performs services that meet the criteria for prolonged services, can the attending bill for the prolonged services in addition to the shared visit?  Who documents the prolonged services?

    Answer:
    Occasionally, two or more visits are clinically required on the same day for the same patient, and performed by both physician and NPP members of the same group. While time cannot be aggregated in these scenarios, because of their different specialty types, the total time spent during the course of a day may reflect a higher level of E&M coding. For example, a CPT code 99232 service performed at 10am, when combined with subsequent services later on the same day, may meet criteria for both time and detail associated with CPT code 99233. In this scenario, one service may be billed for the group as CPT code 99233, when medical necessity and cumulative documentation support the higher level of coding. Updated 6/9/2017

[Return to Top]

[Return to E&M FAQ Index]

Prolonged Services
Web Content Viewer
Web Content Viewer
Complementary Content