This policy reviews the general billing of Prolonged Services with Direct Face-to-Face Patient Contact Service (codes 99354-99357) and without Direct Face-to-Face Patient Contact Service (codes 99358-99359).
Indications and Limitations of Coverage
Prolonged Services with Direct Face-to-Face Patient Contact Service (codes 99354-99357)
Prolonged physician services (code 99356) in the inpatient setting, with direct face-to-face patient contact which require one hour beyond the usual service are payable when they are billed on the same day by the same physician or qualified NPP as the companion evaluation and management codes. Each additional 30 minutes of direct face-to-face patient contact following the first hour of prolonged services may be reported by CPT code 99357.
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 may be used 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.
Required Companion Codes
Prolonged services codes 99354-99357 are not paid unless they are accompanied by the companion codes as indicated. Therefore, when reported independently they will deny as noncovered. A provider cannot bill the member for the denied service.
Requirement for Physician Presence
In the case of prolonged office services, time spent by 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 reviewing charts or discussion of a 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 cannot be billed as prolonged services.
Use of the Codes
If the total duration of direct face-to-face time does not equal or exceed the threshold time for the level of evaluation and management service the physician or qualified NPP provided, the physician or qualified NPP may not bill for prolonged services.
Threshold Times for Codes 99354 and 99355 (Office or Other Outpatient Setting)
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.
The following threshold times will be used to determine if the prolonged services codes 99354 and/or 99355 can be billed with the office or other outpatient settings including outpatient consultation services and domiciliary, rest home, or custodial care services and home services codes.
Threshold Times for Codes 99356 and 99357 (Inpatient Setting)
If the total direct face-to-face time equals or exceeds the threshold time for code 99356 by no more than 29 minutes, the physician bills the visit code 99356 and one unit of code 99357. One additional unit of code 99357 is billed for each additional increment of 30 minutes extended duration.
The following threshold times will be used to determine if the prolonged services codes 99356 and/or 99357 can be billed with the inpatient setting codes.
Prolonged Services Associated With Evaluation and Management Services Based on Counseling and/or Coordination of Care (Time-Based)
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.
Reasons for Noncoverage
Prolonged Services without Direct Face-to-Face Patient Contact Service (codes 99358-99359)
Medical record documentation must support 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.
Examples of Billable Prolonged Services
Examples of Nonbillable Prolonged Services
Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.
Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.
CMS Manual Online Pub. 100-4, Chapter 12, Sections 126.96.36.199-188.8.131.52
Transmittal 1490, CR 5972
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.
Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.
Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.