Medicare Advantage Medical Policy Bulletin

Section: CMS National Guidelines
Number: N-169
Topic: Prolonged Services (See Reference Section)
Effective Date: July 6, 2009
Issued Date: July 6, 2009

General Policy

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 (CPT code 99354) in the office or other outpatient setting with direct face-to-face patient contact which require one hour beyond the usual service are payable when billed on the same day by the same physician or qualified nonphysician practitioner (NPP) as the companion evaluation and management codes. The time for usual service refers to the typical/average time units associated with the companion evaluation and management 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 may be reported by CPT code 99355.

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
Physicians may count only the duration of direct face-to-face contact between the physician and 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.

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
Prolonged services codes can be billed only if the total duration of all physician or qualified NPP direct face-to-face service (including the visit) equals or exceeds the threshold time for the evaluation and management service the physician or qualified NPP provided (typical/average time associated with the CPT E/M code plus 30 minutes).

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 99354, but is less than the threshold time for code 99355, the physician should bill the evaluation and management visit code and code 99354. No more than one unit of 99354 is acceptable, additional units will be denied as noncovered. A provider cannot bill the member for the denied service.

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 Time for Prolonged Visit Codes 99354 and/or 99355 Billed with Office/Outpatient and Consultation Codes

Code

Typical Time
for Code

Threshold Time to Bill
Code 99354

Threshold Time to Bill
Codes 99354 and 99355

99201 10 40 85
99202 20 50 95
99203 30 60 105
99204 45 75 120
99205 60 90 135
99212 10 40 85
99213 15 45 90
99214 25 55 100
99215 40 70 115
99241 15 45 90
99242 30 60 105
99243 40 70 115
99244 60 90 135
99245 80 110 155
99324 20 50 95
99325 30 60 105
99326 45 75 120
99327 60 90 135
99328 75 105 150
99334 15 45 90
99335 25 55 100
99336 40 70 115
99337 60 90 135
99341 20 50 95
99342 30 60 105
99343 45 75 120
99344 60 90 135
99345 75 105 150
99347 15 45 90
99348 25 55 100
99349 40 70 115
99350 60 90 135


Add 30 minutes to the threshold time for billing codes 99354 and 99355 to get the threshold time for billing code 99354 and two units of code 99355. For example, to bill code 99354 and two units of code 99355 when billing a code 99205, the threshold time is 150 minutes.

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, but is less than the threshold time for code 99357, the physician should bill the visit and code 99356. No more than one unit of code 99356 will be accepted, additional units will be denied as noncovered. A provider cannot bill the member for the denied service.

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.

Threshold Time for Prolonged Visit Codes 99356 and/or 99357 Billed with Inpatient Setting Codes


Code

Typical Time
for Code

Threshold Time to Bill
Code 99356

Threshold Time to Bill
Codes 99356 and 99357

99221 30 60 105
99222 50 80 125
99223 70 100 145
99231 15 45 90
99232 25 55 100
99233 35 65 110
99251 20 50 95
99252 40 70 115
99253 55 85 130
99254 80 110 155
99255 110 140 185
99304 25 55 100
99305 35 65 110
99306 45 75 120
99307 10 40 55
99308 15 45 60
99309 25 55 70
99310 35 65 80
99318 30 60 75


Add 30 minutes to the threshold time for billing codes 99356 and 99357 to get the threshold time for billing code 99356 and two units of 99357.

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.

Reasons for Noncoverage

Prolonged Services without Direct Face-to-Face Patient Contact Service (codes 99358-99359) 
Prolonged services codes 99358 and 99359, which do not require any direct patient face-to-face contact (e.g., telephone calls) are considered bundled services. Payment for these services is included in the payment for direct face-to-face services that physicians bill. A provider cannot bill the member separately for the service in this case.

Documentation Requirements

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.

NOTE:
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.

Procedure Codes

99201 99202 99203 99204 99205 99212
99213 99214 99215992219922299223
99231992329923399241 99242 99243
99244 99245 99251992529925399254
992559930499305993069930799308
99309993109931899324 99325 99326
99327 99328 99334 993359933699337
993419934299343993449934599347
993489934999350993549935599356
993579935899359   

Coding Guidelines

Examples of Billable Prolonged Services

Example 1
A physician performed a visit that met the definition of an office visit code 99213 and the total duration of the direct face-to-face services (including the visit) was 65 minutes. The physician bills code 99213 and one unit of code 99354.

Example 2
A physician performed a visit that met the definition of a domiciliary, rest home care visit code 99327 and the total duration of the direct face-to-face contact (including the visit) was 140 minutes. The physician bills codes 99327, 99354, and one unit of code 99355.

Example 3
A physician performed an office visit to an established patient that was predominantly counseling, spending 75 minutes (direct face-to-face) with the patient. The physician should report CPT code 99215 and one unit of code 99354.

Examples of Nonbillable Prolonged Services

Example 1
A physician performed a visit that met the definition of visit code 99212 and the total duration of the direct 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.

Example 2
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.

Example 3
A physician provided a subsequent office visit that was predominantly counseling, spending 60 minutes (face-to-face) with the patient. The physician cannot code 99214, which has a typical time of 25 minutes, and one unit of code 99354. The physician must bill the highest level code in the code family (99215 which has 40 minutes typical/average time units associated with it). The additional time spent beyond this code is 20 minutes and does not meet the threshold time for billing prolonged services.

References

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 30.6.15.1-30.6.15.2

Transmittal 1490, CR 5972

www.cms.gov
www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

Glossary





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.