Prolonged Services: How Do I Document?

To:       Georgia Academy Members

From:    Speaker Carl McCurdy, MD

Vice Speaker Samuel Le Church, MD – GAFP Congress of Delegates

As a follow up to one of our Congress of Delegates resolutions passed last year, CPT consultant Steve Adams generously is allowing us to reprint an article that he has written focusing on prolonged services.  This article is to educate our members on how to code appropriately on extended patient encounter time and additional services.  The Georgia Academy thanks Steve Adams for sharing this article.  If you would like to contact Steve – here is his website:

Prolonged Service

By Steven A. Adams, MCS, CRC, CPMA, CPC, COC, CPC-I, PCS, FCS, COA

Prolonged Services

The CPT definition of prolonged care varies from that of the Centers for Medicare & Medicaid Services (CMS). Since 2009, CPT recognizes the total duration spent by a physician on a given date, even if the time spent by the physician on that date is not continuous; the time involves both face-to-face time and unit/floor time.  CMS only attributes direct face-to-face time between the physician and the patient toward prolonged care billing. Time spent reviewing charts or discussion of a patient with house medical staff, waiting for test results, waiting for changes in the patient’s condition, waiting for end of a therapy session, or waiting for use of facilities cannot be billed as prolonged services.

So, when billing 99215 with a 99354 or 99355 you’d need to first understand the rules associated with billing a prolonged service code along with an EM code when the EM code is based on counseling and coordination of care.

CMS outlines this in section H of the provider manual:

  1. Prolonged Services Associated with Evaluation and Management Services Based on Counseling and/or Coordination of Care (Time-Based)

When an evaluation and management service is dominated by counseling and/or coordination of care (the counseling and/or coordination of care represents more than 50% of the total time with the patient) in a face-to-face encounter between the physician or qualified NPP and the patient in the office/clinic or the floor time (in the scenario of an inpatient service), then the evaluation and management code is selected based on the typical/average time associated with the code levels. The time approximation must meet or exceed the specific CPT code billed (determined by the typical/average time associated with the evaluation and management code) and should not be “rounded” to the next higher level.

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.

In other words, you have to bill the prolonged service codes with the highest code in that particular family of codes, like 99205 or 99215.

Next, you have to understand the thresholds required to select the 99205 and 99215 along with the prolonged service codes:

  • 99205 and 99354 = 90 – 134 minutes of total time
  • 99205 and 99354 and 9935 = 135 minutes or more of total time
  • 99215 and 99354 = 70-114 minutes of total time
  • 99215 and 99354 and 99355 = 115 minutes or more of total time

Now, how do you document the EM and prolonged services for CMS:

Documentation requirements from CMS:

  1. Documentation

Documentation is not required to accompany the bill for prolonged services unless the physician has been selected for medical review. Documentation is required in the medical record about the duration and content of the medically necessary evaluation and management service and prolonged services billed. The medical record must be appropriately and sufficiently documented by the physician or qualified NPP to show that the physician or qualified NPP personally furnished the direct face-to-face time with the patient specified in the CPT code definitions. The start and end times of the visit shall be documented in the medical record along with the date of service.

Finally putting it all together so we maintain compliance – I outline this specifically because CMS does not expect these codes to be used at a high frequency:

Selecting a 99215 and 99354

  • Start: 9:00 end 10:10 = 70 minutes face to face – more than 50% of which was spent in: counseling and coordinating care over the following issues: _______________ (meets requirements of rule D & H above)

Both times together equal (40 + 30) = 70 minutes.  This meets the threshold outlined above for 99215 and 99354 on the same day.