|Title: Time Based Services – Prolonged Services|
|Issued:||12/01/1999||Reviewed/Revision Date:||08/21/2000, 10/06/2009, 07/01/2012, 12/09/2014|
Prolonged Services – (codes 99354, 99355, 99356 and 99357) are used when a physician provides prolonged service involving direct (face-to-face) patient contact that is beyond the usual services in either the inpatient or outpatient setting
Medical Necessity – Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported.
The prolonged services codes are reported in addition to other physician service, including evaluation and management services at any level. Prolonged Service codes are time-based built on the total duration of face-to-face time spent by the physician caring for the patient on a given date; such face-to-face time may occur at discrete intervals throughout the day.
The time for usual service refers to the typical time associated with the companion evaluation and management service as noted in the CPT code.
In the office setting, time spent by office staff with the patient, or time the patient remains unaccompanied in the office cannot be billed. In the hospital setting, time spent reviewing charts or discussion of a 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, or end of a therapy cannot be billed as prolonged services.
A 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.
If time is considered the key or controlling factor in choosing the level of E/M service, then the prolonged services CPT codes (99354 through 99357) should only be used in addition if the service has exceeded 30 minutes beyond the highest level of E/M in the appropriate category
Code 99354: Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (e.g., prolonged care and treatment of a patient having an acute asthmatic attack in an outpatient setting) first hour.
Code 99355: Each additional 30 minutes. (If the final segment of care during the day is between 15 and 30 minutes, this code may be billed for that interval; if the final interval was less than 15 minutes, that interval will not be separately billable under this code).
|Code||Typical Time for Code||Threshold Time to Bill Code 99354||Threshold Time to Bill Codes 99354 and 99355|
Code 99356: Prolonged physician service in the inpatient setting requiring direct (face-to-face) patient contact beyond the usual service (e.g., maternal fetal monitoring for high risk delivery or other physiological monitoring); the first hour.
Code 99357: Each additional 30 minutes. (If the final segment of care during the day is between 15 and 30 minutes, this code may be billed for that interval; if the final interval was less than 15 minutes, that interval will not be separately billable under this code).
|Code||Typical Time for Code||Threshold Time to Bill Code 99356||Threshold Time to Bill Codes 99356 and 99357|
Time spent by Residents
For procedure codes determined on the basis of time, the teaching physician must be present for the period of time for which the claim is made. For example, a code that specifically describes a service of from 20 to 30 minutes may be paid only if the teaching physician is physically present for 20 to 30 minutes. Do not add time spent by the resident in the absence of the teaching physician.
Examples of codes falling into this category include:
- Individual medical psychotherapy (CPT codes 90804 through 90829)
- Critical care services (CPT codes 99291 through 99292)
- Hospital discharge day management (CPT codes 99238 through 99239)
- E/M codes in which counseling and/or coordination of care dominates more than 50 percent of the encounter, and time is considered the key or controlling factor to qualify for a particular level of E/M service
- Prolonged services (CPT codes 99358 through 99359)
- Care plan oversight (HCPCS codes G0181 through G0182)
The medical necessity for performing prolonged services should be clearly documented in the medical record.
Medicare Claims Processing (PUB. 100-04)
Chapter 12 – Physicians/Nonphysician Practitioners
30 – Correct Coding Policy (Updated through Rev. 2282, Issued: 08-26-11, Effective: 01-01-11, Implementation: 11-28-11
Questions regarding policies, procedures or interpretations should be directed to the USC Office of Culture, Ethics and Compliance at (323) 442-8588 or USC Help & Reporting Line at (213) 740-2500 or (800) 348-7454.