There are three ways to pay for time in Evaluation & Management (E&M) codes for inpatient care. Prolonged service codes 99356 and 99357 are one of them.
- Critical care.
- Counseling services for admits, consults and follow up notes.
- Prolonged Service Codes
I'm going to explain #3 for you today. Prolonged service codes are supposed to pay for time spent on patient care beyond the "bundled" payment of current E&M codes. If you spend 10 minutes or 35 minutes on a level three hospital follow up CPT® code (99233), you will get paid the same. The AMA, which owns the CPT® codes, has defined their usage. Their definitions are generally accepted by CMS for payment purposes. Except for the prolonged service codes.
A major change happened in the 2009 CPT® book. The AMA used to define prolonged service codes as only face-to-face time beyond the threshold time defined in the CPT® codes. With the 2009 CPT® book the physician can now count any time spent on the patient care, including all unit/floor time spent.
A major change happened in the 2009 CPT® book. The AMA used to define prolonged service codes as only face-to-face time beyond the threshold time defined in the CPT® codes. With the 2009 CPT® book the physician can now count any time spent on the patient care, including all unit/floor time spent.
However, CMS has not yet changed their rules. They still claim that prolonged service codes must be face-to-face.
So it appears we are in a quandary. You can submit your prolonged service bill based on the AMA's CPT® rules, and yet CMS may not pay, because they haven't changed their application of the rules.
Oh yeah, and some non Medicare insurers don't recognize these codes either.
So how do you bill a prolonged service code (and hope it gets paid?)
These codes kick in after the threshold times have been exhausted for the original E&M code. What are the threshold times for hospital admission, follow up and consultation codes? Here they are:
99221 (low level admit) 30 minutes99222 (mid level admit) 50 minutes99223 (high level admit) 70 minutes99231 (low level hospital follow up) 15 minutes99232 (mid level hospital follow up) 25 minutes99233 (high level hospital follow up) 35 minutes99251 (lowest level hospital consult) 20 minutes99252 (second lowest hospital consult) 40 minutes99253 (mid level hospital consult) 55 minutes99254 (second highest hospital consult) 80 minutes99255 (highest level hospital consult) 110 minutes
What does that all mean? It means before you can even consider doing CPT® medical coding for a prolonged service code, these threshold times for each specific CPT® code must be met, and documented. So lets assume you actually spent 110 minutes on a consult (something I think has never been done in the history of modern medicine). How would you go about billing for your extra time?
CPT® 99356 (inpatient prolonged service codes)
- You must spend up to 60 minutes (minimum of 30 minutes) of additional time past the above threshold times to bill this code.
- You must document the total time spent during the face-to-fact portion of the encounter, and the additional unit or floor time in an additional note or one cumulative note.
- In my state 99356 is worth about 1.7 work RVUs or $60 for the work portion.
CPT® 99357 (inpatient additional prolonged service codes)
- Once you have met the threshold for 99356 (60 minutes) you can bill a 99357 for every additional 30 minutes (minimum of 15 minutes).
- You must again document total time spent during the face-to-face portion of the encounter, and the additional unit or floor time.
- In my state a 99357 is worth 1.7 work RVUs, or about $60
Here is a real life example of how to bill these codes. Lets say you spent 30 minutes working on a hospitalized patient with multiple medical problems. Let's say your documentation supports a high level code 99233. In the chart above, the threshold time is defined as 35 minutes.
Let's say you are asked to come back later in the day to evaluate a change in status. The status may not rise to critical care. Let's say you spend another 40 minutes talking with a family personality that takes up all your time, evaluating the data, speaking with the respiratory therapists reevaluating the data of the day and discussing with other subspecialists on the case.
You will have spent 30 + 40=70 minutes on the patient's care. To bill a prolonged service code you have to spend at least 30 minutes past the defined threshold time. In this case, for a 99233 that is 35 minutes + 30 minutes= 65 minutes. The AMA says it doesn't have to be face-to-face. CMS says it does. So you can bill prolonged service code 99356 and hope it gets paid.
Let's say five hours later you are asked to reevaluate the patient's condition. You go back up and spend another 20 minutes on their care. The day's total is now 30+40+20 = 90 minutes. In order to bill an additional prolonged service code (99357) you have to consume the 35 minute threshold time for 99233, spend another 60 minutes for 99356, and spend at least 15 minutes additional time for the 99357. That would mean you need to spend at least 110 minutes. In this case, you spend 30+40+20 = 90 minutes. You do not qualify for an additional billing of 99357.
However, if your hospitalist partner, who comes on for you spends an additional 30 minutes that night, a total time of 30+40+20+30=120 minutes would meet the threshold for billing an additional 99357.
I can't think of any circumstance where I would spend 75 minutes past the threshold time for any CPT® code in order to bill a 99357. If I'm spending that much time, it's because the patient is really sick and a critical care code would suffice.
I can however, think of many times where a 99356 could be billed. Usually the threshold time can be met when you have difficult patients who then have families that require lots of time. And in these situations, I think, using the prolonged service codes make sense.
As a side note, notice the value placed on these prolonged service codes. For a 99356, spending up to 60 additional minutes of care on a patient is worth only 1.7 work RVUs, or $60 for your education and experience. $60 an hour. Even if you met the minimum 30 minutes, the value of your education and experience is $120 an hour. This is the time value that has been decided as fair by the RUC, a committee controlled by procedural and surgical subspecialists that makes default recommendations to Congress on physician pricing.
Imagine for a moment if the orthopaedic surgeons or the cardiologists placed, on a time based axis, a value of $60-120 an hour on the value of their services.
They would all quit. Which is exactly what is happening to primary care. You get what you pay for.
You can see much more in my free lectures on medical billing and coding.
You can see much more in my free lectures on medical billing and coding.
