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Prolonged Services

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

    Answer:
    Time spent in performance of non face-to-face 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 face-to-face prolonged service codes (99358‒99359) in relation to discharge services (99238‒99239).

    Answer:
    Discharge services (99238‒99239) are not billable with the inpatient face-to-face 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 face-to-face 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 face-to-face 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 face-to-face service while the physician performs the face-to-face 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 face-to-face 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 face-to-face 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 face-to-face prolonged service.
    2. Time spent in the posed scenario is simultaneous, not in excess of the associated service.
    3. Non face-to-face 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 face-to-face 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 face-to-face prolonged service when it exceeds 30 minutes beyond the suggested time for the associated face-to-face service. The service is not billable unless an associated face-to-face encounter occurs. Updated 8/29/2017
     
  7. Does time spent filling out a patient’s disability forms meet the criteria for billing a non face-to-face prolonged service?

    Answer:
    Time spent filling out forms is not billable as non face-to-face 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 face-to-face 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 face-to-face office service by a PCP, subsequent to an associated base hospital visit by a hospitalist.

    Answer:
    A non face-to-face 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 face-to-face time must equal or exceed 31 minutes beyond the average time of the associated base code. The base code and the non face-to-face 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. 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

  12. How is cumulative time spent by group members over a single day counted toward prolonged service?

    Answer: Cumulative time spent with a patient by group members in a single day may be counted to assess the use of a prolonged service code. For this purpose, time spent by both physicians and NPPs may be counted toward total time. Time spent in performance of a single level code (e.g., 99232, suggested time is 25 minutes) must exceed the suggested CPT timeframe by a minimum of 30 minutes in order to add a prolonged service code to the base code. To add a second unit of prolonged service, time spent must meet or exceed 75 minutes beyond the suggested base code timeframe. Of note, each segment of time spent must be carefully documented by each provider who is contributing to the patient’s care during that date of service. Added 8/15/2019 

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