Visit our Location
1584 86th Street, Brooklyn, NY 11228
Give us a Call
(718) 621-5800

WHEN TO USE PROLONGED PHYSICIAN SERVICES

When to use prolonged physician services (with direct face-to-face contact) Certain providers may be rendering and billing for more extensive E/M services than are required by the patient’s presenting problem. Only the level of service required to address the presenting problem should be reported for reimbursement….

  1. When to use prolonged physician services (with direct face-to-face contact)
    Certain providers may be rendering and billing for more extensive E/M services than are required by the patient’s presenting problem. Only the level of service required to address the presenting problem should be reported for reimbursement. Physicians’ services involving patient contact that is beyond the usual E/M service in either an inpatient or outpatient setting may be reported as prolonged services. This service may be reported in addition to other physician services, at any level.

In the case of prolonged office services, time spent by the 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 waiting for test results, for changes in the patient’s condition, for the end of therapy or for the use of facilities cannot be billed as prolonged services. Time spent performing and documenting separately reportable services such as neuro psych and behavioral testing (a service beyond an MMSE), intubation, bronchoscopy, CPR and infusion/chemo administration services may not be reported as a prolonged E/M services.

Codes 99354-99357 are used to report the total duration of face-to-face time spent by a physician providing prolonged service on a given date, even if the time spent by the physician on that date is not continuous. Thus, the total reported prolonged service time for a given date of service should be cumulative. Codes 99354 and 99355 are used when prolonged services are provided in the physicians’ office or other outpatient location. Codes 99356 and 99357 are used for reporting prolonged services provided to inpatients.

The patient’s medical record must be documented to indicate the content of E/M code billed and the duration and content of prolonged services that the physician personally performed. Prolonged physician services should be billed only when the time involved exceeds the typical time of the E/M service by at least 30 minutes. 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 E/M codes. Prolonged services of less than 15 minutes beyond the first hour, or less than 15 minutes beyond the final 30 minutes, is not reported separately.

Threshold Times for Outpatient Services
Prolonged services codes 99354 and 99355 are payable when they are billed on the same day, by the same physician as the companion E/M codes. If the total direct face-to-face time equals or exceeds the threshold time for code 99354, but is less than the threshold time for code 99355, the physician should bill the visit and code 99354, with number of units “1”.

If the total direct face-to-face time equals or exceeds the threshold time for code 99355 by no more than 29 minutes, the physician 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.

Examples of Billable Prolonged Services:

A physician performed a visit that met the definition of visit code 99213 and the total duration of the direct face-to-face medically necessary services (including the visit) was 65 minutes. The physician bills code 99213 and 1 unit of code 99354 (first hour).
A physician performed a visit that met the definition of visit code 99303 and the total duration of the direct face-to-face contact (including the visit) was 115 minutes. The physician bills codes 99303, 99356 (first hour) and 1 unit of code 99357 (each additional 15 minutes).
If the patient has a severe reaction during an infusion or chemotherapy procedure requiring physician intervention, the physician may report a prolonged service if the time required to intervene equaled or exceeded 30 minutes beyond the typical E/M time for that encounter, or for a combined encounter if the physician performed another evaluation and management service to the same patient same day.
Physician provided level 99214 E/M prior to chemo. During chemo administration, patient had severe adverse reaction requiring evaluation by physician. If total service provided did not exceed 40 minutes, the physician may only report 99214-25. If total service equaled or exceeded 55 minutes, the physician may report 99214-25 and 99354.
Please refer to the recent clarification, MMA’ Drug Administration Coding Changes and Reimbursement, Nov. 11, 2004 , page 2 at http://www.cms.hhs.gov/medlearn/matters/mmarticles/2004/SE0462.pdf

Examples of Nonbillable Prolonged Services:

A physician performed a visit that met the definition of visit code 99212 and the total duration of the face-to-face contact (including the visit) was 35 minutes. The physician cannot bill prolonged services because the total duration of direct face-to-face service did not meet the threshold time for billing prolonged services.
A physician performed a visit that met the definition of code 99213 and, while the patient was in the office receiving treatment for 4 hours, the total duration of the direct face-to-face service of the physician was 40 minutes. The physician cannot bill prolonged services because the total duration of direct face-to-face service did not meet the threshold time for billing prolonged services.