Prolonged Care CPT® Service Codes 99354, 99355, 99356, 99357.

This CPT® lecture reviews the prolonged care codes for outpatient services (99354-99355) and inpatient/observation services (99356-99357).  I am a hospitalist physician with over a decade of clinical experience.  I know first hand how confusing evaluation and management (E/M) coding can be.  These prolonged care codes provide an additional level of complexity when trying to  determine the appropriate reimbursement code. Prolonged care codes are not straight forward.  Subtle and not so subtle nuances with their use require understanding by the clinician to remain compliant with Medicare carriers  and other non-Medicare insurance companies.  This CPT® lecture is part of a complete collection of coding  for clinicians.  When you are done reviewing these add-on codes, make sure to review all my lectures at the link provided.

WHEN TO USE PROLONGED SERVICE CODES


CPT® codes 99354-99357 are used when the physician or qualified health care professional provides prolonged service involving direct (face-to-face) patient contact beyond the usual E/M service time threshold. The 2012 CPT® manual removed reference to the term "face-to-face", preferring instead to use direct patient contact.  They define direct patient contact as face-to-face services and non face-to-face services on the patient’s floor or unit in the facility during the same session.  This is different from Medicare which only accepts prolonged service codes for face-to-face time.  Remember this when providing prolonged care for Medicare patients to determine whether or not your documentation would support their use.This is a significant difference in how CPT® defines these codes and how Medicare accepts their use.  In either case, the time spent does not have to be continuous on any given date.

Prolonged service codes are add-on codes that must be reported with a qualifying companion E/M code (listed below).  CPT® codes 99354 and 99355 are prolonged service codes designated for outpatient or clinic settings while CPT® codes 99356 and 99357 are to be used in the inpatient or observation setting.  Codes 99354 and 99356 are the initial prolonged service codes, to be used for the first hour of prolonged service beyond the usual E/M service time threshold and can be reported after the first 30 minutes beyond the usual time threshold of the E/M code.  Codes 99355 and 99357 are, what I like to call, the prolonged, prolonged service codes, that are used to capture time beyond the allowable times of codes 99354 and 99356 respectively.  If you are confused, you're probably not alone.  Keep reading for a thorough understanding.  In addition, I do  recommend obtaining your own copy of the  the American Medical Association's (AMA) 2014 CPT® manual for quick reference and review.  You can get your copy from Amazon, linked through the graphic to the right. 


OUTPATIENT/OFFICE PROLONGED SERVICE CPT® CODE DESCRIPTIONS (99354-99355)

 

As you read these definitions, be aware of the significant differences I have tried to highlight on how the AMA CPT® manual defines these codes and how Medicare recognizes them.  The differences are significant and are the likely source of great frustration for health care providers and coders alike.

  99354


  • AMA:  The AMA in their  most recent CPT® manual describes code 99354 as prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour.  
    • Note, this incorporates their new language and removal of reference to "face-to-face" in the older descriptions .  
  • CMS (page 2):  In the office or other outpatient setting, Medicare will pay for prolonged physician services with direct face-to-face patient contact that requires one hour beyond the usual service, when billed on the same day by the same physician or qualified NPP as the companion evaluation and management codes. The time for usual service refers to the typical/average time units associated with the companion E&M service as noted in the CPT® code. 
    • Note the difference in the AMA definition and Medicare's definition.  Only face-to-face time qualifies for Medicare.  This code can be reported after the first 30 minutes of qualifying time beyond the E/M usual service time on any given date. See the table below for threshold times.

  99355 

 

  • The AMA in their  most recent CPT® manual describes code 99355 as prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes.  Use this code in conjunction with 99354.  Each additional 30 minutes of time beyond the first 60 minutes of qualified prolonged service time reported with code 99354  should be reported with 99355.  Code 99355 can be reported numerous times.  There is no maximum.  The threshold to bill 99355 is met beyond the first 15 minutes past the 60 minute threshold of  code 99354. See the table below for threshold times.   

 

INPATIENT PROLONGED SERVICE CPT® CODE DESCRIPTIONS (99356-99357)


  99356


  • AMA:  The AMA in their  most recent CPT® manual describes code 99356 as prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour.  
    • Since 2009, the CPT® definition of 99356 has allowed  time spent on the unit/floor not in direct face-to-face contact to be used in reporting 99356.  Once again, this is not allowed by Medicare, which requires only time spent in direct face-to-face contact to be reported for this prolonged service code.  
    • Note also the addition of observation setting to the definition.  This can get a bit confusing since observation is considered outpatient and code 99356 is used for inpatient (according to the CMS definition), but that's how CPT® has defined the use of prolonged care with observation services.  I believe this was done to  capture time spent on floor activities in the hospital, based on their new definition of unit/floor time involvement.   In addition,  I have been unable to find any CMS reference that indicates prolonged care codes can  be reported with observation services.  See below for the discussion on acceptable companion codes.
  • CMS (page 2):  In the inpatient setting , Medicare will pay for prolonged physician services code 99356 with direct face-to-face patient contact which require one hour beyond the usual service, when billed on the same day by the same physician or qualified NPP as the companion evaluation and management codes.
    • Note the CMS definition refers to inpatient.  Observation is not inpatient.  This appears to be another conflict on how CMS recognizes this prolonged service code and how the AMA defines it. 
    • Note again the requirement for face-to-face time, a choice of words the CPT® manual completely eliminated in 2012.   

  99357


  • The AMA in their  most recent CPT® manual describes code 99357 as prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; each additional 30 minutes.  Use in conjunction with 99356.  Each additional 30 minutes of time beyond the first 60 minutes of qualified prolonged service time reported with code 99356  should be reported with 99357.  Code 99357 can be reported numerous times.  There is no maximum.  The threshold to bill 99357 is met beyond the first 15 minutes past the 60 minute threshold of  code 99356.  See the table below for threshold times.
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QUALIFYING COMPANION CODES


Prolonged service codes 99354-99357 will not be paid unless they are billed with qualified  companion code(s).  These CMS approved codes are detailed in this excellent Medicare Learning Network resource (page 3) with regards to Change Request 5972 on prolonged service codesHowever, several changes have occurred since this 2008 document, most notably, CMS no longer recognizes consult codes of any kind.  Also,  new time thresholds for observation codes have been defined and new CPT® codes 99224-99226 for observation follow up codes by the attending physician have been created.   I have highlighted, in green below,  the companion codes the AMA CPT® manual says can be used in combination with their respective prolonged service codes but for which I could find no reference to their approval by CMS, despite an exhaustive search.   Remember, just because they are defined as appropriate by the AMA's CPT® manual does not mean CMS will recognize them.   At the moment, I do not know how CMS handles prolonged service codes when submitted with the companion codes listed in green below.  Perhaps some readers could shed some light on that issue. I did find one April 2013 reference on page 65 from a Medicare contractor (NHIC) that discussed acceptable companion codes for prolonged services and they did not indicate any of the green highlighted codes below were acceptable.  I have referenced the AMA's CPT® manual new code adjustments here (page 4) and  here (page 1).

With regards to the observation codes initial care  (99218-99220) and subsequent care (99224-99226), consider the scenario where the attending physician is billing these observation codes and spends an additional 30 minutes beyond the usual E/M time but can't bill for prolonged service using 99356 or 99357 per CPT® definition because these codes are not listed by CMS as companion codes.  However, if a consultant saw the patient, they would use the outpatient new or established codes and could bill for prolonged care, if indicated, using the 99354 and or 99355.  See how quirky this gets?  Why should one doctor get to bill them while another doctor can't, simply because one is the attending and one is a consultant. And if CMS does allow observation codes to be companion codes, the attending would be using 99356-99357 and the consultant would be using 99354-99355 to provide the same prolonged care on the same patient.  Even stranger!   Quite a frustrating scenario to say the least.  My hope is that CMS recognizes the codes in green below as companion codes for prolonged care, although I have been unable to verify that after an extensive review. 

  COMPANION CODES FOR 99354 DEFINED BY CMS (AMA CPT® adjustments in green)

 

  • Office or Other Outpatient visit codes (99201 - 99205, 99212 – 99215)
  • Office or Other Outpatient Consultation codes (99241 – 99245) (CMS no longer recognizes consult codes but other insurances may)
  • Domiciliary, Rest Home, or Custodial Care Services codes (99324 – 99328, 99334 – 99337)
  • Home Services codes (99341 - 99345, 99347 – 99350)
  • Extended psychotherapy (90837)

           

  COMPANION CODES FOR 99355

 

  • 99354 and one of the qualified E/M companion codes.

  COMPANION CODES FOR 99356 (AMA CPT® adjustments in green)


  • Initial Hospital Care codes (99221-99223)
  • Subsequent Hospital Care codes (99231-99233)
  • Inpatient consultation codes (99251-99255) (CMS no longer recognizes consult codes of any kind but other insurances may)
  • Nursing Facility Services codes (99304-99318)
  • Initial Hospital Observation codes (99218-99220)
  • Subsequent Hospital Observation codes (99224-99226)
  • Same Date Admit and Discharge codes (99234-99236)
  • Extended psychotherapy (90837)

  COMPANION CODES FOR 99357


  • 99356 and one of the qualified E/M companion codes

PSYCHIATRY AND PSYCHOTHERAPY CODES (ADDED FEBRUARY, 2014)

 

Please see this 2014 CMS document (MLN Matters SE 1407).   It  reviews when and how to use codes 90833, 90836 and 90838 for psychotherapy when performed with another E&M service 90832, 90834 and 90837 for psychotherapy codes used without another E&M service.

 

TIME THRESHOLD TABLES WITH COMPANION CODES

 

Review these time threshold tables as a quick reference for the total time necessary to bill for prolonged care using a  qualified E/M companion code.  What qualifies for time?  That depends on who your insurance company is.  Remember, the CPT® definition allows for time not directly related to face-to-face time, while Medicare requires all the additional prolonged service time to be face-to-face.  These tables were obtained from CMS references, so they don't include the additional companion codes (in green above) that the AMA CPT® manual says can be used with the prolonged service codes.  I have added in the threshold times for the additional E/M codes not listed in this chart. 

OUTPATIENT COMPANION CODES




Source Medicare Learning Network MM6740 Page 7

  • 99241:  Typical time:  15 minutes; 99354 threshold:  45 minutes; 99354 + 99355:  90 minutes.
  • 99242:  Typical time:  30 minutes; 99354 threshold:  60 minutes; 99354 + 99355:  105 minutes.
  • 99243:  Typical time:  40 minutes; 99354 threshold:  70 minutes; 99354 + 99355:  115 minutes.
  • 99244:  Typical time:  60 minutes; 99354 threshold:  90 minutes; 99354 + 99355:  135 minutes.
  • 99245:  Typical time:  80 minutes; 99354 threshold:  110 minutes; 99354 + 99355:  155 minutes.
  • 90837:  Typical time:  60 minutes; 99354 threshold:  90 minutes; 99354 + 99355:  135 minutes.


INPATIENT/OBSERVATION COMPANION CODES



Source:  Medicare Learning Network MM6740 Page 8
  • 99218:  Typical time:  30 minutes; 99354 threshold:  60 minutes; 99354 + 99355:  105 minutes.
  • 99219:  Typical time:  50 minutes; 99354 threshold:  80 minutes; 99354 + 99355:  125 minutes.
  • 99220:  Typical time:  70 minutes; 99354 threshold:  100 minutes; 99354 + 99355:  145 minutes.
  • 99224:  Typical time:  15 minutes; 99354 threshold:  45 minutes; 99354 + 99355:  90 minutes.
  • 99225:  Typical time:  25 minutes; 99354 threshold:  55 minutes; 99354 + 99355:  100 minutes.
  • 99226:  Typical time:  35 minutes; 99354 threshold:  65 minutes; 99354 + 99355:  110 minutes.
  • 99234:  Typical time:  40 minutes; 99354 threshold:  70 minutes; 99354 + 99355:  115 minutes.
  • 99235:  Typical time:  50 minutes; 99354 threshold:  80 minutes; 99354 + 99355:  125 minutes.
  • 99236:  Typical time:  55 minutes; 99354 threshold:  85 minutes; 99354 + 99355:  130 minutes.
  • 90837:  Typical time:  60 minutes; 99354 threshold:  90 minutes; 99354 + 99355:  135 minutes.

DOCUMENTATION REQUIREMENTS: WHAT COUNTS AND WHAT DOESN'T

 

 

WHAT COUNTS?


What are the documentation requirements for using prolonged service codes.  Since these are time based codes, time must be documented.  In Medicare Learning Network document MM5972 (page 4), CMS specifically says to make sure "you document the start and end times of the visit, along with the date of service".  I don't know how a Medicare carrier would respond to documentation that shows a total time for the visit instead of start and stop time documentation.  The prolonged care service does not have to be continuous on any given date. Since CMS is telling us a start and stop time is required, I would document a start and stop time instead of total time.

They say the medical record does not need to be sent when billing for prolonged services, unless that visit has been selected for medical review.  They also indicate documentation of the "content of the medically necessary evaluation" is needed.   Because CMS says prolonged care services must be face-to-face, MM5972 also says documentation in the medical record must indicate that the service was personally furnished with direct face-to-face time.  Other insurance companies may have different documentation requirements.  In addition, I highly recommend reviewing Chapter 12 of the Medicare Claims Processing Manual for a detailed review of prolonged care codes.  This is where many of the compressed Medicare Learning Network documents come from.  On page 86, they detail the requirement for physician presence.
Physicians may count only the duration of direct face- to-face contact between the physician and the patient (whether the service was continuous or not) beyond the typical/average time of the visit code billed to determine whether prolonged services can be billed and to determine the prolonged services codes that are allowable. In the case of prolonged office services, time spent by office staff with the patient, or time the patient remains unaccompanied in the office cannot be billed. In the case of prolonged hospital services, 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, for end of a therapy, or for use of facilities cannot be billed as prolonged services.


WHAT DOESN'T?


For outpatient visits, one Medicare carrier provider education document says  time spent by the office staff with the patient or time the patient remains unaccompanied in the office cannot be billed. This is detailed in the paragraph above.  Medicare has  specifically stated that time spent on the floor or unit   should not be counted toward the use of the prolonged care codes.  This contradicts the newer CPT® definitions of prolonged service codes.  They have also stated that time spent in gathering information from the family or discussing the medical plan with family not in the presence of the patient does not count toward the use of prolonged care codes.  I think this is a tragedy.  The family will often request not to be in the room when critical life decisions are being made about patients.  Many times, the patient is too fragile to leave the room and conference rooms down the hall do not allow transfer of hospital beds so doctors can get paid for high quality communication with family members.  Often, patients are too demented or too confused to offer any input into their medical decisions and face-to-face discussions with the powers of attorney are the only tool doctors have to make decisions.  The fact that Medicare would not consider these discussions as medically necessary and pay physicians for their time is disheartening to say the least. Their definition for what they are willing to pay for is a hindrance to high quality medical care.  I am personally embarrassed by how they have chosen to apply their rules to prolonged care services.  It slaps in the face of all their other efforts to increase communication for complex medical patients. 

What about separately reportable services such as CPR, infusio/chemo, intubation, bronchoscopy, neuro psych and behavioral testing?  Medicare says to make sure the time spent involved in these types of procedures are not being used in determining face-to-face time for prolonged care services. 

As with most coding issues, documentation to support the additional face-to-face time (for Medicare) or other non face-to-face direct patient contact as medically necessary should be meticulously provided.  Explain the complexity of the discussions with the patient and family members as well as communication with other medical team members including doctors, nurses, pharmacists and respiratory therapists.  Explain the content of your discussion and any extenuating circumstances that may require additional provider time such as any financial, economic, social, insurance or legal issues that indicate extra time was medically necessary.  This will help support any questions of medical necessity if the service is audited.

Will doctors and other non-physician practitioners get paid by Medicare for non face-to-face efforts?  They specifically say no on page page 90/231 from The Medicare Claims Processing Manual Chapter 12.
 
Contractors may not pay prolonged services codes 99358 and 99359, which do not require any direct patient face-to-face contact (e.g., telephone calls). Payment for these services is included in the payment for direct face-to-face services that physicians bill. The physician cannot bill the patient for these services since they are Medicare covered services and payment is included in the payment for other billable services.

I can assure you, Medicare does not pay for this under other codes as they claim they do.  The time involved doing all this extra work goes far beyond the usual time of the E/M codes.  99358 and 99359  specifically apply to extensive record review or other time not spent face-to-face with the patient/caregiver or unit/floor time in the hospital or nursing facility.    When I'm spending over 90 minutes running grunt work on highly complex patients, reviewing piles of paper records from transfer facilities, talking with subspecialists, outpatient pharmacists to get cash only pricing on a Medicare patient who chose not to sign up for Medicare Part D, calling the primary care physician, calling the patient's three doctor sons and daughters with 45 questions each,  I can assure you, this is not included in my E/M charge.  The reason more doctors won't provide this level of service is because it's not paid for, despite what CMS believes.  Just because the physician is not face-to-face with the patient does not mean the work they are providing is not just as important to provide high quality care. More tragedy.  Consider also that some non-Medicare carriers may not recognize prolonged service codes of any kind.  

DIFFERENT PHYSICIANS, SAME PRACTICE


Since different physicians in the same specialty and practice function as one, Medicare should pay for multiple physicians involved in the same patient encounter that rises to prolonged service.   CMS won't pay more than one E/M code per day.  If my partner evaluated a patient earlier in the day and billed a hospital follow up code and then I was called to the bedside as the on call physician, unless I was able to bill critical care, my service is uncompensated.   However, I may be able to bill for prolonged service if my time, in combination with my partners time, reached the necessary thresholds based on their chosen E/M charge.  Unfortunately, there are many barriers to this method.  Most of my colleagues to not include a start and stop time on their non-ICU notes.  That, by itself prevents me from knowing how much time I would have had to spend to reach the prolonged service time thresholds.  Perhaps some newer EHR systems provide that start and stop time automatically and would allow cross covering physicians to better capture payment for their time in face-to-face encounters.

In addition, I am not sure how CMS computers would rectify having an E/M charge by one physician and a prolonged service code by another physician.  Even though they are in the same group and same specialty, they require submission with companion codes and having two different  physicians provide separate E/M and prolonged service codes may trigger an algorithmic rejection.   In the past, I know there were difficulties with ICU add-on codes 99292 when submitted by a different physician than the one who provided 99291 work for cross covering physicians.  Perhaps this problem has been fixed.  Perhaps it has not.


HOW TO USE PROLONGED CARE CODES WHEN E/M SERVICE IS BILLED BASED ON TIME

 

How should the clinician bill for prolonged care services when they have provided and documented their E/M companion code based on time?  CMS has defined exactly how to handle this situation.  The Medicare Claims Processing Manual, Chapter 12 Section 30.6.15.1 C   (starting on  page 85) is the CMS go-to resource for understanding prolonged service codes.  Starting on  page 89, CMS discusses how to handle prolonged care during E/M counseling sessions.
In those evaluation and management services in which the code level is selected based on time, prolonged services may only be reported with the highest code level in that family of codes as the companion code.
What does that mean for the hospitalist?  That means if you bill a hospital follow up code based on counseling and time requirements, only CPT® 99233 can be used, the highest code in the group of hospital subsequent care codes. That means in each group of companion codes, only the highest E/M code in the family can be used and the time threshold for that code must be met before prolonged care time begins.  That means if you provided 15 minutes out of 25 minutes of time based counseling smf  qualify for a level two 99232 hospital follow up visit based on time, and then you go back and provide an additional 30 minutes of face-to-face time for a total of 55 minutes, you cannot bill for a 99232 plus a 99356.  Only 99233 and 99356 can be billed in this situation and the threshold for time is 65 minutes (35 + 30), not 55 minutes.   This is an important nuance that physicians and non-physician practitioners should  understand to prevent denial of payment. 


RVU VALUE OF PROLONGED SERVICE CODES



How much are the prolonged service codes worth in relative value terms? The RVU dollar conversion factor in 2014 is 35.8228.
  • 99354:  Work RVU 1.77
    •  Total RVU facility 2.61;  about $88
    • Total RVU non-facility  2.80; about $95
  • 99355:  Work RVU  1.77
    • Total RVU facility 2.55;  about $86
    • Total RVU non-facility 2.74;  about $92
  • 99356:  Work RVU  1.71
    • Total RVU facility or non-facility  2.58; about $87
  • 99357:  Work RVU  1.71
    • Total RVU facility or non-facility  2.56;  about $87
How often are these prolonged services codes billed to Medicare?  Here is data from the most recent 2011 CMS Part B National Procedure Summary Files data (2011 zip file) showing how many CPT® 99354-99357 encounters were billed and the dollar value of their services for Part B Medicare.  
  • 99354
    • Allowed services - 262,557
    • Allowed charges - $25,087,779.23
    • Payments - $19,440,700.07
  • 99355
    • Allowed services - 28,703
    • Allowed charges - $2,722,598.70
    • Payments - $2,159,451.03
  • 99356
    • Allowed services - 191,930
    • Allowed charges - $16,709,300.61
    • Payments - $13,266,275.54
  • 99357
    • Allowed services - 13,431
    • Allowed charges - $1,149,928.18
    • Payments - $915,639.27

Hopefully, this lecture has helped to shed some light on the complexities of prolonged service codes and how differently they are treated by Medicare compared with how they are defined by the CPT® manual.  In addition to this lecture and collection of lectures linked at the top of this article, make sure to review my hospitalist resources area for a wealth of other important information.  


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