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.

STANDARD

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

Outpatient

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
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
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

Inpatient

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
99221	30	60	105
99222	50	80	125
99223	70	100	145
99231	15	45	90
99232	25	55	100
99233	35	65	110

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)

Medical Necessity

The medical necessity for performing prolonged services should be clearly documented in the medical record.

REGULATORY REFERENCES

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

Questions regarding policies, procedures or interpretations should be directed to the USC Office of Culture, Ethics and Compliance at (323) 442-8588 or USC Report & Response at (213) 740-2500 or (800) 348-7454.