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Prolonged Services (Codes 99354-99359) (NPP) (PHY)
Posted May 7, 2008
MLN Matters Number: MM5972
Related Change Request (CR) #: 5972
Related CR Release Date: April 11, 2008
Related CR Transmittal #: R1490CP
Effective Date: July 1, 2008
Implementation Date: July 7, 2008
The National Provider Identifier (NPI) Will Be Required for All Health Insurance Portability and Accountability Act (HIPAA) Standard Transactions on May 23rd. As of May 23, 2008, the NPI will be required for all HIPAA standard transactions. This means:
- For all primary and secondary provider fields, only the NPI will be accepted and sent on all HIPAA electronic transactions (837I, 837P, NCPDP, DDE, 276/277, 270/271 and 835), paper claims (UB-04 and CMS-1500), and standard paper remittance (SPR) remittance advice; and
- Reporting of Medicare legacy identifiers in any primary or secondary provider fields will result in the rejection of the transaction.
Provider Types Affected
Physicians and other qualified non-physician practitioners (NPPs) whose services are billed to Medicare carriers or Part A/B Medicare Administrative Contractors (A/B MACs).
What You Need to Know
Change Request (CR) 5972, from which this article is taken, updates the sections of the Medicare Claims Processing Manual that address prolonged services codes, in order to be consistent with changes/deletions in codes and changes in typical/average time units in the American Medical Association (AMA) Current Terminology Procedural Terminology (CPT) coding system.
Make sure that your billing staffs are aware of the prolonged services CPT code changes as described in the "Background" section below.
Background
Since Medicare Claims Processing Manual, Chapter 12 (Physicians/Nonphysician Practitioners), §§30.6.15.1 (Prolonged Services With Direct Face-to-Face Patient Contact Service (Codes 99354-99357) (ZZZ codes)) and 30.6.15.2 (Prolonged Services Without Direct Face-to-Face Patient Contact Services (Codes 99358-99359)) were first written, several code changes, code deletions, and typical/average time units have changed in the AMA CPT coding system.
CR 5972, from which this article is taken, updates these sections that address prolonged services codes, in order to be consistent with the AMA CPT coding changes.
These manual changes:
- (In keeping with current Medicare payment policy for physician presence and supporting documentation) define prolonged services and explain the required evaluation and management (E&M) companion codes;
- Correct and update the tables for threshold times (reproduced below) to reflect code changes and current typical/average time units associated with the CPT levels of care in code families; and
- In a new subsection (30.6.15.1(H)), explain how to report physician visits for counseling and/or coordination of care when the visit is based on time and when the counseling and/or coordination service is prolonged.
A summary of these manual changes follows.
Prolonged Services Definitions
In the office or other outpatient setting, Medicare will pay for prolonged physician services (CPT code 99354) (with direct face-to-face patient contact that requires one hour beyond the usual service) when billed on the same day by the same physician or qualified NPP as the companion E&M codes. The time for usual service refers to the typical/average time units associated with the companion E&M service as noted in the CPT code. You should report each additional 30 minutes of direct face-to-face patient contact following the first hour of prolonged services with CPT code 99355.
In the inpatient setting, Medicare will pay for prolonged physician services (code 99356) (with direct face-to-face patient contact which require one hour beyond the usual service) when billed on the same day by the same physician or qualified NPP as the companion E&M codes. You should report each additional 30 minutes of direct face-to-face patient contact following the first hour of prolonged services with CPT code 99357.
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 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.
Required Companion Codes
Please remember that prolonged services codes 99354-99357 are not paid unless they are accompanied by the companion codes as described here.
The companion E&M codes for 99354 are:
- Office or other outpatient visit codes (99201-99205, 99212-99215),
- Office or other outpatient consultation codes (99241-99245),
- Domiciliary, rest home, or custodial care services codes (99324-99328, 99334-99337),
- Home services codes (99341-99345, 99347-99350).
The companion E&M codes for 99355 are 99354 and one of its required E&M codes.
The companion E&M codes for 99356 are the initial hospital care and subsequent hospital care codes (99221-99223, 99231-99233), the inpatient consultation codes (99251-99255); nursing facility services codes (99304-99318).
The companion codes for 99357 are 99356 and one of its required E&M codes.
Requirement for Physician Presence
You may count only the duration of direct face-to-face 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 cannot 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 face-to-face 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. Documentation, however, is required to be in the medical record about the duration and content of the medically necessary E&M service and prolonged services that you bill.
You must appropriately and sufficiently document in the medical record that you personally furnished the direct face-to-face 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.
Use of the Codes
You can only bill the prolonged services codes if the total duration of all physician or qualified NPP direct face-to-face service (including the visit) equals or exceeds the threshold time for the E&M service the physician or qualified NPP provided (typical/average time associated with the CPT E&M code plus 30 minutes).
Threshold Times for Codes 99354 and 99355 (Office or Other Outpatient Setting)
If the total direct face-to-face time equals or exceeds the threshold time for code 99354, but is less than the threshold time for code 99355, you should bill the E&M visit code and code 99354. No more than one unit of 99354 is acceptable.
If the total direct face-to-face time equals or exceeds the threshold time for code 99355 by no more than 29 minutes, you should bill the visit code 99354 and one unit of code 99355. One additional unit of code 99355 is billed for each additional increment of 30 minutes extended duration.
Table 1 displays threshold times that your carriers and A/B MACs use to determine if the prolonged services codes 99354 and/or 99355 can be billed with the office or other outpatient settings, including outpatient consultation services and domiciliary, rest home, or custodial care services and home services codes. The AMA CPT coding-derived changes are noted in bolded italics.
Table 1
Threshold Time for Prolonged Visit Codes 99354 and/or 99355 Billed with Office/Outpatient and Consultation Codes
| 99201 |
10 |
40 |
85 |
| 99202 |
20 |
50 |
95 |
| 99203 |
30 |
60 |
105 |
| 99204 |
45 |
75 |
120 |
| 99205 |
60 |
90 |
135 |
| 99212 |
10 |
40 |
85 |
| 99213 |
15 |
45 |
90 |
| 99214 |
25 |
55 |
100 |
| 99215 |
40 |
70 |
115 |
| 99241 |
15 |
45 |
90 |
| 99242 |
30 |
60 |
105 |
| 99243 |
40 |
70 |
115 |
| 99244 |
60 |
90 |
135 |
| 99245 |
80 |
110 |
155 |
| 99324 |
20 |
50 |
95 |
| 99325 |
30 |
60 |
105 |
| 99326 |
45 |
75 |
120 |
| 99327 |
60 |
90 |
135 |
| 99328 |
75 |
105 |
150 |
| 99334 |
15 |
45 |
90 |
| 99335 |
25 |
55 |
100 |
| 99336 |
40 |
70 |
115 |
| 99337 |
60 |
90 |
135 |
| 99341 |
20 |
50 |
95 |
| 99342 |
30 |
60 |
105 |
| 99343 |
45 |
75 |
120 |
| 99344 |
60 |
90 |
135 |
| 99345 |
75 |
105 |
150 |
| 99347 |
15 |
45 |
90 |
| 99348 |
25 |
55 |
100 |
| 99349 |
40 |
70 |
115 |
| 99350 |
60 |
90 |
135 |
To get to the threshold time for billing code 99354 and two units of code 99355, add 30 minutes to the threshold time for billing codes 99354 and 99355. For example, when billing code 99205, in order to bill code 99354 and two units of code 99355, the threshold time is 150 minutes.
Threshold Times for Codes 99356 and 99357 (Inpatient Setting)
If the total direct face-to-face time equals or exceeds the threshold time for code 99356, but is less than the threshold time for code 99357, you should bill the visit and code 99356.
Medicare contractors will not accept more than one unit of code 99356. If the total direct face-to-face time equals or exceeds the threshold time for code 99356 by no more than 29 minutes, you should bill the visit code 99356 and one unit of code 99357. One additional unit of code 99357 is billed for each additional increment of 30 minutes extended duration.
Table 2 displays the following threshold times that your Medicare contractors use to determine if the prolonged services codes 99356 and/or 99357 can be billed with the inpatient setting codes. The AMA CPT coding-derived changes are noted in bolded italics.
Table 2
Threshold Time for Prolonged Visit Codes 99356 and/or 99357 Billed with Inpatient Setting Codes
| 99221 |
30 |
60 |
105 |
| 99222 |
50 |
80 |
125 |
| 99223 |
70 |
100 |
145 |
| 99231 |
15 |
45 |
90 |
| 99232 |
25 |
55 |
100 |
| 99233 |
35 |
65 |
110 |
| 99251 |
20 |
50 |
95 |
| 99252 |
40 |
70 |
115 |
| 99253 |
55 |
85 |
130 |
| 99254 |
80 |
110 |
155 |
| 99255 |
110 |
140 |
185 |
| 99304 |
25 |
55 |
100 |
| 99305 |
35 |
65 |
110 |
| 99306 |
45 |
75 |
120 |
| 99307 |
10 |
40 |
85 |
| 99308 |
15 |
45 |
90 |
| 99309 |
25 |
55 |
100 |
| 99310 |
35 |
65 |
110 |
| 99318 |
30 |
60 |
105 |
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 percent of the total time with the patient) in a face-to-face 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.
Billing Examples
Examples of billable and non-billable prolonged services follow.
- 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 face-to-face 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 face-to-face 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 face-to-face) 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 face-to-face contact (including the visit) was 35 minutes. The physician cannot bill prolonged services because the total duration of direct face-to-face 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 face-to-face service of the physician was 40 minutes. The physician cannot bill prolonged services because the total duration of direct face-to-face 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 (face-to-face) 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 face-to-face contact (e.g., telephone calls). These are Medicare covered services and payment is included in the payment for other billable services.
Additional Information
You can find more information about billing with prolonged services codes 99354-99359 by going to CR 5972, located at www.cms.hhs.gov/transmittals/downloads/R1490CP.pdf on the Centers for Medicare & Medicaid Services (CMS) Web site. You will find the updated Medicare Claims Processing Manual, Chapter 12 (Physicians/Nonphysician Practitioners), §§30.6.15.1 (Prolonged Services With Direct Face-to-Face Patient Contact Service (Codes 99354-99357) (ZZZ codes)) and 30.6.15.2 (Prolonged Services Without Direct Face-to-Face Patient Contact Services (Codes 99358-99359)) as an attachment to that CR.
If you have any questions, please contact your carrier or A/B MAC at their toll-free number, which may be found at www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site. For the Upstate Medicare Division (UMD), you can call the toll-free provider line at 877-567-7173.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2007 American Medical Association. |
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