With the elimination of consultation codes by the Centers for Medicare and Medicaid Services (CMS), many rheumatology practices are finding it a heavy burden to bill the appropriate codes for the time they spend with patients.
Current Procedural Terminology (CPT) allows for time to become the key factor in coding for an evaluation and management service if more than 50% of the visit is spent face to face with the patient. For example, a typical level-five new patient outpatient visit is 60 minutes, but a typical level-five outpatient consultation visit is 80 minutes; in many cases, a rheumatologist could spend far more time than that on a consultation. This leaves rheumatologists with the dilemma of limiting the number of Medicare patients they see or finding a better way to code these visits.
The answer to this problem can be found in prolonging CPT codes—if documented and billed correctly.
Many rheumatology practices are finding success with the billing of prolonged services. There are two categories of prolonged services—prolonged physician service with direct (face-to-face) patient contact and prolonged physician services without direct (face-to-face) patient contact. When considering billing for prolonged services, pay close attention to the local coverage determination or the carrier’s contract to verify that there is reimbursement for these codes.
The first of the two prolonged services should be used after a visit has been lengthened because of counseling and coordination of care that was more than 50% of the face-to-face time of the visit. If it is an outpatient visit, it will typically be a 99205 visit, which typically takes 60 minutes. If the rheumatologist finds himself or herself spending at least another 30 minutes with the patient face to face, the additional prolonged codes can be billed. The CPT definitions of the face-to-face levels of these codes for outpatient services are:
- +99354: Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service; first hour (list separately in addition to code for office or other outpatient Evaluation and Management service)
- +99355: Each additional 30 minutes (list separately in addition to code for prolonged physician service)
Coders and billers should be aware that these codes are add-on codes and cannot be billed without an office or outpatient visit.
Elimination of consultation codes by CMS also has had a large impact on inpatient visits. CMS instructed billers, coders, and physicians to bill the first contact with a patient as an initial visit and any contact with that patient during that confinement as subsequent. While inpatient consultation codes had five levels, initial and subsequent hospital visits only have three levels. Typically, in the highest level of initial hospital visit, physicians will spend 70 minutes face-to face with a patient, according to the 2010 CPT Manual. On the other hand, a level-five visit of an inpatient consultation typically had the physician spending 110 minutes. This could be longer with a complicated rheumatology patient. Again, if the rheumatologist is spending more than 30 minutes with the patient face to face beyond what he or she would expect with the highest level of an inpatient visit, he or she is allowed to bill the prolonged code.
Here are the CPT definitions of the face-to-face level of these codes for inpatient services:
- +99356: Prolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual service; first hour (list separately in addition to code for inpatient Evaluation and Management service)
- +99357: Each additional 30 minutes (list separately in addition to code for prolonged physician service)
Coders and billers should be aware that these codes are add-on codes and cannot be billed without an inpatient visit.
Remember that documentation is the key to billing all CPT codes. The prolonged codes are based on time, so it is extremely important to document the complete time of the visit—this includes what was done and discussed with the patient. If there is no substantiating documentation for the time, the codes will be considered not medically necessary. For additional information about prolonged codes, contact Melesia Tillman, CPC, CRHC, CHA, at (404) 633-3777, ext. 820, or [email protected].
