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July 17, 2018 - Revised: 08.07.18

Prolonged Services (CPT Codes 99354 – 99359)

The Comprehensive Error Rate Testing (CERT) program has recently reviewed prolonged E/M services that were found to be in error for the following reasons:

  • Missing documentation to support start/end times of the visit for billed prolonged E/M
  • Missing documentation to support the medical necessity

Prolonged Service with Direct Patient Contact (99354-99357)

  • Direct patient contact is Face-to-Face (F2F) and includes additional non-F2F services on the floor/unit in hospital or nursing facility during the same session
  • Reported in addition to the primary procedure
  • Time spent performing separately reported services other than E/M or psychotherapy service NOT counted toward prolonged service
  • Less than 30 minutes total duration is NOT separately reported.

Total Duration of Prolonged Services

Codes

Less than 30 minutes

Not reported separately

30-74 minutes

99354x1

75-104 minutes

99354x1 AND 99355 x1

105 or more

99354x1 AND 99355x2 or more for ea additional 30 minutes

Prolonged Service WITHOUT Direct Patient Contact (99358 and 99359)

  • May be reported on a different date than the primary service
    • i.e. extensive record review may relate to previous E/M service
  • MUST relate to service where a F2F HAS OR WILL occur AND relate to patient management
  • Report total duration of non F2F even if the time spent on that date is not continuous
  • Only use once per date

Do NOT use for:

  • Care plan oversight services
  • Anticoagulant management
  • Medical team conferences
  • On-line medical evaluations
  • Other F2F services that have more specific codes

The above information can be found in CPT Professional Edition, Prolonged Services

In addition CGS would like to bring to your attention a recent MLN Matters article:

Prolonged Services (Codes 99354 – 99359)’ MLN Number MM5972External PDF

A few highlights from this publication are as follows:

Prolonged Services Associated With E&M Services Based Counseling and/or Coordination of Care (Time-Based)
When an E&M service is dominated by counseling and/or coordination of care (the counseling and/or coordination of care represents more than 50% of the total time with the patient) in a F2F encounter between the physician or the qualified NPP and the patient in the office/clinic or the floor time in the scenario of an inpatient service, the E&M code is selected based on the typical/average time associated with the code levels. The time approximation must meet or exceed the specific CPT code billed (determined by the typical/average time associated with the E&M code) and should not be “rounded” to the next higher level. Further, in E&M services in which the code level is selected based on time, you may only report prolonged services with the highest code level in that family of codes as the companion code.

NOTE:  You should not separately report prolonged service of less than 30 minutes total duration on a given date, because the work involved is included in the total work of the evaluation & management (E&M) codes

You may use code 99355 or 99357 to report each additional 30 minutes beyond the first hour of prolonged services, based on the place of service. These codes may be used to report the final 15 – 30 minutes of prolonged service on a given date, if not otherwise billed. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately

Requirement for Physician Presence:

You may count only the duration of direct F2F contact with the patient (whether the service was continuous or not) beyond the typical/average time of the visit code billed, to determine whether prolonged services can be billed and to determine the prolonged services codes that are allowable.

You can only bill the prolonged services codes if the total duration of all physician or qualified NPP direct F2F 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).

DO NOT BILL AS PROLONGED SERVICES:
In the office setting, time spent by office staff with the patient, or time the patient remains unaccompanied in the office; or

In the hospital setting, time spent reviewing charts or discussing the patient with house medical staff and not with direct F2F contact with the patient or waiting for test results, for changes in the patient’s condition, for end of a therapy, or for use of facilities

Documentation:
Unless you have been selected for medical review, you do not need to send the medical record documentation with the bill for prolonged services.  However, documentation about the duration and content of the medically necessary evaluation and management service and prolonged services billed should be noted in the medical record. 

You must appropriately and sufficiently document in the medical record that you personally furnished the direct F2F time with the patient specified in the CPT code definitions. Make sure that you document the start and end times of the visit, along with the date of service.

Billing Examples

PLEASE NOTE WHEN RECORDING TIME YOU MUST INCLUDE START/STOP TIMES

Billable Prolonged Services

EXAMPLE 1

A physician performed a visit that met the definition of an office visit CPT code 99213 and the total duration of the direct F2F services (including the visit) was 65 minutes. The physician bills CPT code 99213 and one unit of code 99354.

EXAMPLE 2

A physician performed a visit that met the definition of a domiciliary, rest home care visit CPT code 99327 and the total duration of the direct F2F contact (including the visit) was 140 minutes. The physician bills CPT codes 99327, 99354, and one unit of code 99355.

EXAMPLE 3

A physician performed an office visit to an established patient that was predominantly counseling, spending 75 minutes (direct F2F) with the patient. The physician bills CPT code 99215 and one unit of code 99354.

Non-billable Prolonged Services

EXAMPLE 1

A physician performed a visit that met the definition of visit code 99212 and the total duration of the direct F2F contact (including the visit) was 35 minutes. The physician cannot bill prolonged services because the total duration of direct F2F service did not meet the threshold time for billing prolonged services.

EXAMPLE 2

A physician performed a visit that met the definition of code 99213 and, while the patient was in the office receiving treatment for 4 hours, the total duration of the direct F2F service of the physician was 40 minutes. The physician cannot bill prolonged services because the total duration of direct F2F service did not meet the threshold time for billing prolonged services.

EXAMPLE 3

A physician provided a subsequent office visit that was predominantly counseling, spending 60 minutes (F2F) with the patient. The physician cannot code 99214, which has a typical time of 25 minutes, and one unit of code 99354. The physician must bill the highest level code in the code family (99215 which has 40 minutes typical/average time units associated with it). The additional time spent beyond this code is 20 minutes and does not meet the threshold time for billing prolonged services.

Finally, you should remember that Medicare contractors will not pay (nor can you bill the patient) for prolonged services codes 99358 and 99359, which do not require any direct patient F2F contact (e.g., telephone calls). These are Medicare covered services and payment is included in the payment for other billable services.

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