Knowing the Story for Prolonged Services

The past few years have marked some significant changes to prolonged services. This blog shares an overview of the prolonged services codes, CMS criteria, and notable risk areas.  

The first prolonged code set is designed to use with outpatient services.

*+99354 (3.66 RVU) Prolonged evaluation and management or psychotherapy service(s) beyond the typical time of the primary procedure in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (see time thresholds in reference link)

**+99355 (2.76 RVU) each additional 30 minutes

 As stated in the AMA definition, these prolonged codes are meant to be used in addition to office visit evaluation and management (E/M) codes (99201-99215), and also with limited psychotherapy services.  Understanding these add-on codes can apply to all levels of service and not only to the highest level.  CMS also clarifies these codes as direct “face-to-face” with the patient.  If the provider is spending both face-to-face and non-face-to-face time, this will need to be separated for purposes of billing.  Codes do not require the service to be continuous throughout the day.

Caution with using in addition to psychotherapy services as many code are not applicable.  For example, prolonged services may be billed with CPT® 90837 Psychotherapy, 60 minutes with patient and/or family member.  A minimum of 90 minutes must be documented for the encounter (e.g., 60 minutes of psychotherapy, plus at least 30 minutes of prolonged services). Prolonged services codes cannot be reported with CPT® +90838 Psychotherapy, 60 minutes with patient and/or family member when performed with an E/M service (List separately in addition to the code for primary procedure).

The second code set is used in addition to inpatient services (see CPT book for all applicable codes).

+99356 (2.6 RVU) Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient evaluation and management service)

+99357 (2.6 RVU) prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; each additional 30 minutes.  Use in conjunction with 99356

Prolonged service can be very useful in capturing revenue if multiple visits (same provider, group/specialty) are medically necessary and face-to-face time is clearly documented by all parties.  Yet, CMS explicitly states that in the hospital setting, non-face-to-face time spent reviewing charts or discussing the patient with house medical staff, outside of face-to-face contact, cannot count towards prolonged services. Likewise, this extends to waiting for test results, changes in the patient’s condition, waiting for end of therapy, or for use of facilities (i.e. room fee).

The third set, non-face-to face prolonged care, have recently earned their merit with CMS and many private payors.  This is one of the few E/M code sets that do not require the patient to be present.  The key to using these consist of detailed documentation, a time component, and confirming patient care will occur or has occurred and relate to ongoing management.  For example, take an oncology patient transferring to a new cancer center out of state.  Dr. Smith receives the records one week before the patient arrives.  He spends 60 minutes reviewing and summarizing her history and treatment in preparation of her first visit the following week.   This example would suffice to use code 99358 without the patient being present.

99358 (3.16 RVU) Prolonged evaluation and management service before and/or after direct patient care; first hour

+99359 (1.52 RVU) additional 30 minutes (List separately in addition to code for prolonged physician service)

New Codes for Prolonged Services by Clinical Staff

New in 2016, the AMA created two new codes addressing prolonged care provided by clinical staff when supervised by a physician or qualified healthcare provider.

+99415 (0.25 RVU) Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour (List separately in addition to code for outpatient Evaluation and Management service)

+99416 (0.13 RVU) each additional 30 minutes (List separately in addition to code for prolonged service)

This series only applies to office outpatient CPT codes 99201-99215.  Code 99415 may be coded in addition to the primary E/M service for the initial 45-74 minutes of prolonged clinical staff services above and beyond the published base code CPT time.  As with other prolonged codes, time counted does not have to be continuous, however, time spent by clinical staff performing other, separately reportable services do not count toward prolonged time.

Additional requirements in order to use these codes include the following:

·       Report 99415 once, per date

·       Neither code may be reported with other prolonged services

·       Documentation must indicate direct supervision by a physician or other qualified healthcare provider

·       Facilities are restricted from billing these services.

Prolonged Risk Areas

In a June 2017, Noridian conducted a focused pre-payment review using 613 claims to evaluate the documentation for prolonged services in addition to E/M codes.  An astounding 89.63% error rate was found mainly due to inadequate documentation not meeting CMS guidelines.

Looking back into the 2015 and 2016 OIG Workplan, prolonged services have long been a focused target.  The Workplan summary states: we will determine whether Medicare payments to physicians for prolonged evaluation and management services were reasonable and made in accordance with Medicare requirements. Prolonged services are for additional care provided to a beneficiary after an evaluation and management service has been performed. Physicians submit claims for prolonged services when they spend additional time beyond the time spent with a beneficiary for a usual companion evaluation and management service. The necessity of prolonged services are considered to be rare and unusual. The Medicare Claims Process (MCP) manual includes requirements that must be met in order to bill a prolonged E/M service code. (MCP manual, Pub. 100-04, Ch. 12, Sec. 30.6.15.1(OAS; W-00-15-35755; expected issue date: FY 2016)

Learn by example with the prolonged series.  Find a physician champion who has stellar documentation and an understanding of when these codes are appropriate.  Educate, educate, educate your coders, and providers so they can improve documentation and communication to stay off the radar from government audits.

REFERENCES

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/mm5972.pdf

https://oig.hhs.gov/reports-and-publications/archives/workplan/2016/oig-work-plan-2016.pdf

https://med.noridianmedicare.com/web/jeb/cert-reviews/mr/reviews/prolonged-service-in-the-office-or-other-outpatient-setting-99354-99355-southern-ca-service-specific-targeted-review-findings)