CPT code 99354 – Prolonged Visit

CPT 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)

The average reimbursement is in the range of $95.00, depending upon your region.

The Medicare Manual says:

The start and end times of the visit shall be documented in the medical record along with the date of 

service.

This code is one of many under-utilized codes in your office for many reasons. However, if you do the work and spend the prolonged time, face to face with the patient, document the progress note properly and provide the required medically necessary components, you deserve to use this code and get paid for your time.

Serious Illness Takes Serious Time

This code can be used for a seriously ill patient in your office, when you are spending a significant amount of time helping, while deciding the best course of action. This would include deciding to admit the patient to the hospital or sending the patient to the emergency room via a 911 call.

Usually, if you are spending over 40 minutes with the patient and have all of the criteria, you are going to document and bill for a 99215.  However, if you end up spending any additional time, for example, over another 30 minutes with the patient, and your face-to-face total time counting all other services is 75 minutes or more, you may be entitled to capture the additional CPT code 99354.

Record Your Time!

It is prudent to report the start times and the ending times as well as the face-to-face time, in order to properly capture this code.

Overall, this really is not that difficult.  For example, if you have a patient who comes into your office with an exacerbation of their COPD, you may start the patient on oxygen in your office while you perform your History, Physical and Medical Decision Making.

Keep Track of the Intensity of your Care

In the course of this you may order a nebulizer treatment for the patient and then leave the room to see another patient, you should document the time actually spent with the patient up to that point.

Once you return to the room the clock starts again. While speaking with the patient regarding how they feel after the nebulizer treatment, you may decide that they need an injection or another treatment. You document the time and then may have to leave the room to see another patient.

Once you return to the room, the clock starts again; so each time you decide on a treatment option for this patient, you continue to accrue time towards, not only the level CPT 99215 visit as the patient definitely will meet criteria for the intensity and medical necessity, you are potentially capturing the extra time needed to use the CPT 99354 code.

This code will enable you to be able to bill for the extra time you need to spend with the patient while you are stabilizing them, in order to decide if they can return home be transported to the hospital.

Many of us have the occasional patient who will use a significant amount of time in order for you to take proper care of them, to stabilize them and to decide whether the current problem they have can be handled from home or in the hospital.

Code Correctly for your Visit Too

If you provide the care, you deserve the code. That is why it is available in the first place. You owe it to yourself to maximize your revenue. Many providers will only bill this encounter as a CPT 99213 or CPT 99214. The reality is, if you do the work and properly document with the medical necessity in place, you can easily and comfortably bill for the appropriate code CPT 99215 and CPT 99354.

Definition, changes , use of code - prolonged visits

Changes in Prolonged Services Codes

The Medicare Claims Processing Manual has been updated to address prolonged services codes in order to be consistent with changes/deletions in codes and changes in typical/average time units in the American Medical Association Current Procedural Terminology (CPT) coding system. The manual changes define Prolonged Services and explain the required evaluation and management (E&M) companion codes.

Prolonged Services Definitions

– In the office or other outpatient setting

o Medicare will pay for prolonged physician services (CPT code 99354) 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 E&M 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. Each additional 30 minutes of direct face to face patient contact following the first hour of prolonged services with CPT code 99355.

– In the inpatient setting

o Medicare will pay for prolonged physician services (code 99356) with direct face to face patient contact which requires one hour beyond the usual service when billed on the same day by the same physician or qualified NPP as the companion E&M codes. Each additional 30 minutes of direct face‐to‐face patient contact following the first hour of prolonged services with CPT code 99357.

You should not separately report prolonged service of less than 30 minutes total duration on a given date, because the work involved is included in the total work of the E&M codes.

You may use code 99355 or 99357 to report each additional 30 minutes beyond the first hour of prolonged services, based on the place of service. These codes may be used to report the final 15-30 minutes of prolonged service on a given date, if not otherwise billed. 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.

Note: Prolonged Service Codes 99354 – 99357 are NOT paid unless they are accompanied by the appropriate visit specific E&M companion codes.

Requirement for Physician Presence

You may count only the duration of direct face‐to‐face contact with 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.

You cannot bill as prolonged services:

– In the office setting, time spent by office staff with the patient or time the patient remains unaccompanied in the office.

– In the hospital setting, time spent reviewing charts or discussing the 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.

Documentation

Unless you have been selected for medical review, you do not need to send the medical record documentation with the bill for prolonged services. Documentation, however, is required to be in the medical record about the duration and content of the medically necessary E&M services and prolonged services that you bill.

You must appropriately and 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. Make sure that you document the start and end times of the visit, along with the date of service.

Use of the Codes

You can only bill the prolonged services codes if the total duration of a physician or qualified NPP direct face‐to‐face service (including the visit) equals or exceeds the threshold time for the E&M service the physician or qualified NPP provided (typical/average time associated with the CPT E&M code plus 30 minutes).

Threshold Times for Codes 99354 and 99355 (Office or Other Outpatient Setting)

If the total direct fact‐to‐face time equals or exceeds the threshold time for code 99354, but is less than the threshold time for code 99355, you should bill the E&M visit code and code 99354. No more than one unit of 99354 is acceptable.

If the total direct face to f ace time equals or exceeds the threshold time for code 99355 by no more than 29 minutes, you should bill the visit code 99354 and one unit of code 99355. One additional unit of code 99355 is billed for each additional increment of 30 minutes extended duration.

cpt codes 99354 - 99357

Prolonged Physician Service with Direct (Face-to-Face) Patient Contact (99354-99357)

Codes 99354-99357 are used when a physician provides prolonged service involving direct (face-to-face) patient contact that is beyond the usual service in either the inpatient or outpatient setting. This service is reported in addition to the designated evaluation and management services at any level and any other physician services provided at the same session as evaluation and management services. Appropriate codes should be selected for supplies provided or procedures performed in the care of the patient during this period.

Codes 99354-99355 are used to report the total duration of face-to-face time spent by a physician on a given date providing prolonged service, even if the time spent by the physician on that date is not continuous. Codes 99356-99357 are used to report the total duration of unit time spent by a physician on a given date providing prolonged service to a patient, even if the time spent by the physician on that date is not continuous.

Code 99354 or 99356 is used to report the first hour of prolonged service on a given date, depending on the place of service.

Either code should be used only once per date, even if the time spent by the physician is not continuous on that date. Prolonged service of less than 30 minutes total duration on a given date is not separately reported because the work involved is included in the total work of the evaluation and management codes.

Code 99355 or 99357 is used to report each additional 30 minutes beyond the first hour, depending on the place of service. Either code may also be used to report the final 15-30 minutes of prolonged service on a given date. 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.

The use of the time based add-on codes requires that the primary evaluation and management service have a typical or specified time published in the CPT codebook.

The following examples illustrate the correct reporting of prolonged physician service with direct patient contact in the office setting:

Total Duration of Prolonged Services    Code(s)

less than 30 minutes   -  Not reported separately

30-74 minutes (30 minutes - 1 hr. 14 min.)  -  99354 X 1

75-104 (1 hr. 15 min. - 1 hr. 44 min.)  - 99354 X 1 AND 99355 X 1

105 or more (1 hr. 45 min. or more)  -  99354 X 1 AND 99355 X 2 or more for each additional 30 minutes

99354Prolonged 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)

(Use 99354 in conjunction with 99201-99215, 99241-99245, 99324-99337, 99341-99350, 90809, 90815)

99355Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service;each additional 30 minutes (List separately in addition to code for prolonged physician service)

(Use 99355 in conjunction with 99354)

99356Prolonged 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)

(Use 99356 in conjunction with 99221-99233, 99251-99255, 99304-99310, 90822, 90829)

99357Prolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual service;each additional 30 minutes (List separately in addition to code for prolonged physician service)

(Use 99357 in conjunction with 99356)