Prolonged Services: Are you losing money because you didn't understand how or when to use these codes?

Lack of understanding and fear of the prolonged service codes is the main cause of improper billing of them.  I am certain that after reading this article, you will have a clear understanding of how and when to use these codes and that you will begin to utilize them when applicable. 

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 provider of service on these issues as well on how and why you utilize these codes.   

The prolonged service code range is 99354  99357.  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.  This is physician face-to-face time spent; staff time does not count toward it, waiting for results does not qualify, but the time can be cumulative.  A physician, a nurse practitioner or a physician assistant can bill for prolonged service.

You must be able to document the necessity of the level of E/M service billed as well as the additional time.  Hospital Observation Care service, Emergency Department Services (the nature of emergency services makes seeing multiple patients at a time and documenting actual time spent with patient nearly impossible), Critical Care services, and Discharge Day services are excluded. 

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 http://www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf  .