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Prolonged Services: Face-to-Face

NGS JK MAC has noted an increase in claims representing face-to-face prolonged service codes, submitted as add-on codes for other E&M services. This article will provide an enhanced understanding of CMS guidelines for these codes, given the relatively unique or unusual circumstances in which face-to-face prolonged service codes may be appropriately billed.

Coding Guidelines

These CPT codes (Outpatient: 99354-99355, Inpatient: 99356-99357) describe E&M services that require significant additional time spent providing direct clinical care and/or counseling, in face-to-face contact with the patient. For noncounseling visits, the documented history, exam and medical decision elements of the base E&M service may meet any level of service; the prolonged service code defines a situation in which that level of clinical care required more than 30 minutes beyond the time reference found in the CPT Manual for that code. For example, a visit coded at 99212 is associated with a suggested 10 minute timeframe. If that visit required more than 40 minutes of direct face-to-face time, for a medically necessary reason, an add-on prolonged service code might be appropriate. Medical necessity for prolonged service time must be clearly inferred in the provider’s documentation.

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Counseling and Coordination of Care

When 50 percent or more of E&M visit time is spent in counseling and coordination of care, time spent dictates the level of coding. For example, if a provider spends 30 minutes of face-to-face office time in counseling a patient, that visit may be coded as 99214, since the CPT-suggested timeframe for 99214 is 25 minutes. In this situation, the history, examination and medical decision making elements do not necessarily need to meet expectations for 99214, since the visit is coded based on time. A prolonged service code may not be added to the base service in this instance, unless time exceeds the CPT-suggested timeframe for 99215 (40 minutes) by greater than 30 minutes. This would require documentation of a face-to-face visit of greater than 70 minute duration, and details on the medical necessity for that length of time. The general nature of the problem and counseling must be described in the medical record, and the risks and complexity associated with the problem must correlate to the amount of time spent. Further, for E&M services in which the code level is based on time, you may only report prolonged services with the highest level in that family of codes as the companion code. 

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Office versus Hospital Setting

Prolonged care time, in hospital or office settings, represents face-to-face time spent by the rendering provider, either a physician or NPP, in the presence of the patient, for a medically necessary reason. Time spent with any other ancillary office or hospital staff, including professional nursing staff, cannot be included in calculating prolonged service time.

In the hospital setting, time spent for a base E&M service may represent both face-to-face and floor time, relative to the patient’s care and care coordination. Prolonged service, however, must exclusively represent extended face-to-face time by the rendering provider. Of note, in the teaching hospital setting, time spent by residents in the absence of the attending physician cannot count toward prolonged service.

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Physicians versus Nonphysician Practitioners

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. A 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.

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Excluded Time

Time spent in the following ways does not count toward face-to-face prolonged service and is excluded:

  • reviewing medical records or diagnostic results when not present with the patient
  •  discussing the patient with house medical staff or time spent “rounding” with house staff, when not in direct face-to-face contact with the patient
  •  time spent waiting for test results, for changes in the patient’s condition, for end of a therapy, or for use of facilities
  • telephone conversations with either the patient, family or other caregivers

Given the general standards of practice for office and hospital care, NGS expects that billing for these services should be relatively uncommon, unless unusual mitigating factors existed in a defined patient population.

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Examples

The examples below describe several scenarios in which these codes may or may not be appropriately billed:

Appropriate

  • Patient communication through a language interpreter may prolong time spent in a service, especially for a new patient with a complicated clinical history and presenting problem(s). In this situation, a 99204 visit (usually 45 minutes face-to-face) may require over 75 minutes. The provider would need to document the details of the encounter and the exact time spent, some of which would be attributable to the interpreter’s role.
  • An established patient with long history of asthma is treated in the office for an acute asthmatic episode, requiring care at the 99213 level (usually 15 minutes). The provider administers nebulizer treatments and steroidal agents and remains with the patient for a full 50 minutes until symptoms subside and the patient is able to leave the office.
  • A hospitalist spends 25 minutes at the bedside for a 99232 hospital visit. On that same day, the same provider visits that patient two more times, for episodes of pain and moderate respiratory distress. These two latter visits require an additional 40 minutes of time, so a prolonged service code may be appropriately added to the 99232.
  • A hospitalist visits a patient on the 3rd day after admission and initially spends time on the unit reviewing the patient’s medical record and recent diagnostic study results over a period of 20 minutes. The hospitalist then proceeds to the patient’s bedside, where he/she performs a detailed examination and lengthy discussion with the patient and family members discussing the diagnostic results and possible treatment options. The total time spent is 80 minutes (20 minutes of unit time and 60 minutes of face-to-face time) and the services billed are 99233 and 99356.

Inappropriate

  • An office patient presents during an acute allergic reaction, and the provider performs a 15-minute visit at the 99213 level, during which a steroid injection is administered and the patient is instructed sit in the waiting area for 45 minutes before being re-evaluated. Although the patient was in the office suite for more than 60 minutes, face-to-face time with the provider did not meet the level of prolonged service.
  • An office visit includes a mid-level history and exam (usually 15 minutes) but the total duration of the visit is 40 minutes, since the provider spent an additional 35 minutes discussing recent diagnostic results and treatment options for a newly diagnosed lung malignancy. In this scenario, the service should have been coded as 99215, since counseling comprised more than 50 percent of face-to-face time, and 99215 bears a suggested timeframe of 40 minutes.

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Prolonged Services: Face-to-Face
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