2012 CPT Code Changes: Billing Prolonged Services, Part I

These days, who wouldn’t want to be paid a little extra for spending more time caring for patients? This question may particularly resonate with providers who spend a significant amount of time counseling and coordinating care for critically ill patients, those working in an inpatient setting, or those in a variety of specialties.

When providers render prolonged services—i.e., services that go beyond those associated with the usual evaluation and management (E/M) services—they may qualify for additional reimbursement. That’s because coders can capture these services using certain CPT® codes (99354-99359) when documentation reflects the added time and effort spent with patients and when certain other criteria are met.

Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC, director of education at the AAPC in Salt Lake City, provided an overview of 2012 CPT code changes and new CPT guidelines for 2012 related to prolonged services as well as what physicians and coders should keep in mind.

Take it step by step

New CPT guidelines for 2012 remind coders that physicians as well as other qualified healthcare professionals (e.g., nurse practitioners or physician assistants) may perform prolonged services, permitted the services are within the provider’s scope of practice. This is important to remember when ensuring that all providers receive credit for the work they perform.

Like other E/M codes, codes that denote prolonged services are time-based CPT codes. When reporting prolonged services, coders must first note the total time the provider spends with the patient. Does it exceed the time included in the description for the primary E/M code? If so, a prolonged service code may be warranted.

Coders should encourage providers to clearly document either the total time spent with the patient or a start and stop time for the duration of the session. Documentation of start and stop times may be clearer in the event of an audit, although this format is not required.

Keep in mind that codes 99354-99357 are add-on codes. This means coders must report them in conjunction with the appropriate E/M code. The caveat to this is that the prolonged service must exceed 30 minutes in order to separately report it. Any prolonged services performed for fewer than 30 minutes are reimbursed as part of the E/M code and should not be separately reported.

For example, a provider spends 45 minutes performing a level one, face-to-face office visit for a new patient. Coders should report 99201 (which captures the first 10 minutes) and 99354 (to capture an additional 35 minutes). However, if a provider spends 25 minutes performing a level one, face-to-face office visit for a new patient, coders should only report 99201, as the additional 15 minutes does not meet the prolonged service threshold for separate reporting.

Note that the time providers spend rendering prolonged services may not be continuous. New CPT guidelines state coders should report one prolonged services code per date to capture the total duration of time spent regardless of whether it was continuous.

Next, determine whether the provider has direct contact with the patient when providing the prolonged service. Report a code(s) from the 99354-99357 range (for direct patient contact) or a code(s) from the 99358-99358 range (for indirect patient contact), depending on the total time spent and the setting in which the service is provided.

In Part II of this post, we’ll review how CPT defines direct patient contact and how to capture indirect prolonged services, a more challenging task.

Lisa A. Eramo is a freelance writer and editor specializing in medical coding, health information management, and other healthcare regulatory topics. Visit her website at http://lisaeramo.wordpress.com/.

For additional information on 2012 CPT code changes, read our recent articles Getting Paid in 2012: 2012 CPT Code Changes and More, CPT Changes for 2012: An Overview and 2012 CPT Code Changes: Reporting Procedures Related to Pacemakers and Cardioverter-Defibrillators.