Tuesday, August 12, 2014

Prolonged Services codes CPT 99354 - 99357

Prolonged Services billing is allowed by Medicare in the Office, other Outpatient and Inpatient settings, the Prolonged Service codes are used as add-on codes to E&M codes to indicate the extra time that the Physician has spent face-to-face with the patient.

The Prolonged Service codes are billed based on the length of time spent with the patient beyond the usual time required for the E&M code billed, the time spent with the patient need not be continuous but it must be time spent in one calendar day and must be time spent face-to-face with the patient.

For Office/Outpatient settings :


CPT 99354 can be billed when the provider spends direct face-to-face time of more than one hour beyond the usual service/typical time for the E&M code. Additional 30 minutes of face-to-face time with patient can be reported by CPT Code 99355.

For Inpatient settings :


CPT 99356 can be billed when the provider spends direct face-to-face time of more than one hour beyond the usual service/typical time for the E&M code.
Additional 30 minutes of face-to-face time with patient can be reported by CPT Code 99357.

Prolonged service cannot be billed when the prolonged service duration is less than 30 minutes as then it would be considered as included in the E&M code billed.

Prolonged services of less than 15 minutes beyond first hour or less than 15 minutes beyond the final 30 minutes cannot be billed.


Total time of Prolonged services
Outpatient
Inpatient
(do not include visit code time)
Prolonged Services Code
Prolonged Services Code
Less than 30 minutes
Not reported
Not reported
30 – 74 minutes
99354
99356
75 – 104 minutes
99354 and 99355
99356 and 99357

As regards the documentation, the documentation needs to be explicit, documentation is required to be in the medical record about the duration and content of  the medically necessary evaluation and management service and prolonged  services that you bill. 

You must sufficiently document in the medical record that you  personally furnished the direct face-to-face time with the patient specified in the CPT code definitions.   The progress note has to have the start and end times of the visit, along with the date of service.

Friday, August 8, 2014

Signing of Medical Records

Medical Records need to be signed once the services are rendered, the medical record is authenticated when a Provider signs the document.

Payers expect records to be signed within 24 Hrs after services are rendered. In the case of EHR, the records need to be signed electronically.

Medical records that are not signed and records that are signed after a unreasonable delay may not be accepted and could lead to financial and legal implications.

Importance of Documentation

Medical Documentation is very important from a Clinical, Financial and Legal standpoint. 

From a Clinical perspective medical documentation establishes the following,
  • the Patient receiving the Service
  • the Physician providing the Service
  • the Plan of Care provided by the Physician
  • the Diagnosis justifying Medical necessity
  • the Procedures performed, the Labs ordered
  • the Quantity of Service such as consumables
  • other details such as Place of service / Date of service e.t.c

From a Financial perspective medical documentation establishes the following,
  • proper adjudication of claims
  • timely payment of claims

From a Legal perspective medical documentation establishes,
  • the justification for the procedures performed
  • Legal protection for the Patients and Physicians

The Physician / Provider has to document all the procedures performed and sign the document, procedures that are not documented would be considered as not performed and would not be eligible for payment.