INSIGHTS FOR HEALTH CARE 

JUNE 23, 2016   
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Health Care News Network (HCNN), is published on an as-needed basis to keep you informed of current news impacting health care organizations.
 

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Clarifying CPT Prolonged Care Codes
 
By: Susan Rohde, RHIT, CCS-P, CPC
 
Since their inception in 2012, CPT Prolonged Care codes 99354-99359 have been under scrutiny by payers. In 2016, the Office of Inspector General (OIG) put them on its annual work plan. The OIG will now determine whether Medicare payments to physicians for these prolonged services were made in accordance with Medicare requirements. The Centers for Medicare and Medicaid Services (CMS) has stated the usage of prolonged care codes is "rare and unusual."
 
In order to better understand the prolonged care codes, we must determine the documentation requirements of each code.
 
Prolonged Service & Direct Patient Contact Codes 99354-99357
In the office or outpatient setting, Medicare will pay for prolonged physician services if they're billed on the same day by the same physician (or other qualified NPP) as an add-on code to the Evaluation and Management (E/M) code assigned for that date of service.

The typical/average time for the service can be confusing. This refers to the typical/average time associated with the companion E/M code that the prolonged code will be assigned. CPT has assigned average times to almost all the E/M codes, and these are found in the CPT manual after each appropriate code. For example, CPT code 99213, established patient office or outpatient visit, has a typical time of 15 minutes while CPT code 99204, new patient office or outpatient visit, is 45 minutes.
 
In the inpatient setting, Medicare will pay for prolonged physician services if they're billed on the same day by the same physician (or other qualified NPP) as an add-on code to the E/M code assigned for that date of service. Inpatient E/M codes, like their outpatient counterparts, are assigned a typical time.
 
Learn more about direct patient contact codes here. 

Questions?
To learn more about prolonged care codes, please contact Susan Rohde at 701.239.8540 or srohde@eidebailly.com. Or contact your Eide Bailly representative.

 
Susan Rohde, RHIT, CCS-P, CPC
Physician Coding Manager
701.239.8540

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