I originally wrote about prolonged services for BC Advantage Magazine in February/March issue of 2008. At that time, I was surprised after billing for and doing so many revenue consults with practices that so few providers were even aware that these codes existed.

I think that since that time, many providers have attempted to adopt these codes into their practices. However, I still believe that the lack of understanding and fear of the prolonged service codes is the main cause of improper billing of them. A service becomes eligible as a "prolonged service" when a provider spends 30 minutes or more beyond the AMA's average time with a patient for a given E/M (evaluation & management) service. Because documentation of time spent and context is so important, you may need to educate your providers on the proper use of the codes and what documentation is required.

The prolonged service code range is 99354 through 99357 and now 99415 and 99416 which are out of sequence. These are all add-on codes. This means that you cannot bill these codes without an evaluation and management service that is documented according to CPT guidelines for history, exam, and medical decision-making. There must be very clear documentation as to the necessity and clarity of time spent with the patient. For Medicare coverage, this is physician face-to-face time spent even though in 2012, AMA changed the CPT verbiage of codes to state "direct patient care." For codes 99354 through 99357, staff time does not count, waiting for results does not qualify, but the time can be cumulative. The change from face-to-face to "direct patient care" allowed a provider to be on the floor for other carriers that do not follow Medicare guidelines. A physician, a nurse practitioner, or a physician assistant can bill for prolonged services using 99354- 99357.

You must be able to document the necessity of the level of E/M service billed as well as the additional time. Proof of your time is integral to billing prolonged services. Documentation and reporting problems are the main reasons physicians fail to capture this revenue. Without an actual minute value recorded in the patient's record, you cannot code prolonged services no matter how much time is spent with the patient. There are various ways for tracking this and it is well worth the effort to have the documentation and collect for this service when it is rendered. Documentation should be kept in the medical record as it does not need to be submitted to the insurer unless requested for review.

Documentation requirements for E/M services can be located and downloaded at https://www.cms.gov/outreach-and-education/medicare-learning-network-MLN/MLNedwebguide/emdoc.html.

You may be asking yourself "Under what circumstances would this code become a part of my specialty?" For 2016, revisions to these codes include language that allows them to be used with psychotherapy codes as well. Examples include: your healthcare provider examines an established patient in the office and has documented all requirements of 99213, but during the encounter, the patient had an extremely high blood pressure reading. The provider then spends a total of 50 minutes intermittently personally rechecking the pressure reading with the patient to ensure that this is not anxiety related and indeed true hypertension. The provider of service kept accurate documentation in the chart of time spent with patient during each of those intervals and documented the reason for the additional time in the medical record. When multiple providers from the same group examine a patient in the hospital on the same day (for an acute case for instance), their cumulative time spent with the patient may qualify them for prolonged services if they are billing their services as incident to. The provider billing for prolonged services must be the same as the companion E/M. Oncologists may use this if a patient had an adverse reaction to medication requiring additional face-to-face time with provider.

There is always controversial debate about using prolonged service for extra time spent with a patient when a translator is involved. Medicare and most other payers will reimburse for additional time spent with a patient, but they cannot be billed for the costs of providing auxiliary aids and services, either directly or through the patient's insurance carrier per federal regulations (28 C.F.R. § 36.301 (c). The Vermont Medical Society has documentation on their website which supports charging prolonged services in this instance if the documentation meets all coding requirements. You can request a booklet, ADA Questions and Answers for Health Care Providers from the National Academy, Gallaudet University, 800 Florida Avenue NE, Washington DC 2002-3695. I would advise discussing this with your health care attorney (for matters like these, it is very important that you have an attorney whom specializes in health care) as well as developing a practice compliance policy. You should also reference the Medicare Claims Processing Manual (100- 4); Ch. 12; Sec 30.6.15.1.

Threshold times are defined by the AMA. These are based off surveys of practicing physicians to obtain data on the amount of time and work associated with typical E/M services. These are intra-service times which are defined as face-to-face time for the office and other outpatient visits and as unit/floor time for hospital and other inpatient visits. The times in the table are the typical threshold times as defined by AMA in the Medicare Processing Manual.

Codes 99358-99359 do not require face-to-face contact. For this reason, Medicare considers payment for these services included in the E/M, thus making it non-reimbursable from Medicare and the many carriers that follow Medicare guidelines. It is important to check with each carrier for their rules regarding payment of these two codes.

The biggest change for 2016 is the addition of CPT codes 99415 and 99416. These are for E/M codes that require prolonged clinical staff time under the supervision of physician or "qualified healthcare professional" and time that includes face-to-face services by the physician or healthcare provider in the office or other outpatient setting. These codes are exclusively for outpatient use and do not have to be continuous. 99415 is for the first hour of prolonged service and 99416 is used to report additional 30 minutes beyond the first hour.

That is interesting is that the 2016 OIG work plan happens to be looking at the use of prolonged services to determine "reasonableness of services" and this may be low hanging fruit for them. Frequently when I audit charts for providers, I find the requirement for the documentation of time spent to be an area of weakness for most providers. When they do document their time, I had found that often, the same practices do not document the reason for prolonged services.

The 2016 work plan states: 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 is 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)
There are many factors that need to be taken into consideration when billing prolonged services. It is another source of reimbursement that should not be ignored by those who are providing this service. As always, I recommend that you make sure you are educated about the coding and above all else that the medical necessity requirement has been met.

Threshold time for prolonged visit codes 99354 and/or 99355 billed with office/outpatient and consultation codes can be found at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1490CP.pdf

Merrilee Severino, CPC, CMMP, NC, is the CEO of Your Business Medic, a national billing service and credentialing company. She has over 25 years' experience in billing, coding, and practice management. You can reach Merrilee at 727-408-0225 msppmrc@gmail.com