2015 EM Survival Guides

Transcription

1 2015 EM Survival Guides Chapter 13: Prolonged Service: Face-To-Face ( ) Used sparingly and with care, prolonged services codes ( ) can enhance your reimbursement to more than double when the physician must spend justifiable extended time with a patient. Outpatient E/M Time Must Be Face-to-Face To report office or other outpatient prolonged services correctly ( ), you can count only the minutes the physician spent in direct, face-to-face contact with the patient. For inpatient prolonged services codes ( ). As per AMA Guideline you can count all unit/floor time the physician spent treating the patient toward your prolonged services total. This includes time spent discussing the patient s case with other physicians, time reviewing data or tests without the patient present, or other activities not involving direct patient contact, but contributing to the patients treatment. Report Only With Approved Codes You may append prolonged service add-on codes to other E/M codes that include a reference time (without this time component, there is no way to define a service as prolonged). Specifically you should apply (Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management service]) and ( each additional 30 minute..s) with: / Office or other outpatient visit, new or established patient Office consultation * for a new or established patient. In addition, CPT states that you can use with Each of these codes was assigned a time component for reporting.. Similarly, you must use (Prolonged physician service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management service]) and ( each additional 30 minutes..) with: Initial/Subsequent nursing facility care, per day Nursing facility discharge day management Annual nursing facility assessment Initial hospital care, per day Subsequent hospital care, per day Initial inpatient consultations * for a new or established patient. Getting to Know Prolonged services are a unique category of E/M codes that describe physician actions that are beyond the usual service in either the inpatient or outpatient service, according to CPT. Such situations may occur if a patient is noncompliant or requires special attention due to a mental or physical handicap, or if the surgeon must explain complex diagnoses, treatment options or substantial lifestyle changes to the patient. Applicable codes include: Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management service) each additional 30 minutes (List separately in addition to code for prolonged service)

2 99356 Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient Evaluation and Management service) each additional 30 minutes (List separately in addition to code for prolonged service). You should report these services in addition to other physician services, including E/M services at any level, and you may bill and only in addition to and Document at Least 30 Additional Minutes If you wish to report the first hour of prolonged services, the physician must document at least an additional 30 minutes beyond the reference time of the chosen E/M service level. Per CPT requirements, a provider fulfills an hour service once she has accomplished and documented half of it (at least 30 minutes). Similarly, a half-hour service is fulfilled when at least 15 minutes has been accomplished and documented. See the chart, below, for a complete list of threshold times for reporting the first hour of prolonged services with various E/M codes: Prolonged Services For Outpatient E/Ms E/M Code Minimum Total Document Time New Patients min min min min min. Established Patients Prolonged services are NOT reported w/ro min min min min. New or Established Outpatient Consults (Used for office or emergency room consults) min min min min min. Prolonged Services For Outpatient E/Ms E/M Code Minimum Total Document Time Admissions min.

3 min min. Follow-up Hospital Care min min min. Inpatient Consults min min min min min. Discharges You may not charge prolonged services with discharge codes,but which discharge code you use is determined by documented floor time Up to 30 min Over 30 min. Emergency E/M codes You may not use prolonged services codes ( ) with emergency E/M codes ( ). If an admission follows an ER E/M, attach the prolonged service code to the admission. For example, if you select an E/M service with a reference time of 15 minutes (such as 99231, Subsequent hospital care, per day Counseling and/or coordination of care with other physicians, other qualified healthcare professionals Typically 15 minutes are spent at the bedside and on the patient s hospital floor or unit), the physician must document a minimum of 45 minutes of face-to-face time before you can report an initial prolonged service code. Tip: To find the reference time for a particular E/M code, look to the last sentence of the CPT descriptor. For example, the final sentence in 99202s descriptor (Office or other outpatient visit... Counseling and/or coordination of care with other physicians, other qualified healthcare professionals Typically 20 minutes are spent face-to-face with the patient and/or family) specifies, Physicians typically spend 20 minutes face-to-face with the patient and/or family. In this case, 20 minutes is the reference time. Look for add-on opportunities: If you wish to report more than an hour of prolonged services, the physician must document a minimum of 75 minutes (60 for the first hour of prolonged service and another 15 minutes to qualify for the additional half hour) beyond the chosen E/M services reference time. Returning to the above example, if the physician spends at least 90 minutes with the patient and reports 99231, you may also code for prolonged services using (for the first hour beyond the 15-minute reference time of 99213) and (for the additional 15 minutes, which qualifies for the add-on code of an additional 30 minutes of prolonged services beyond the first hour).

4 The chart below illustrates proper coding for prolonged services with direct patient contact for the outpatient setting: Total Duration of Prolonged Services beyond E/M ref. Time Codes Less than 30 minutes not reported separately minutes 99354x minutes 99354x 1, x minutes 99354x 1, x minutes 99354x 1, x minutes 99254x1, 99355x4 Remember: You should report only a single unit of either or per date of service, but you can report multiple units of or per day. Also, you cannot report without first reporting 99354, nor can you report without first reporting Document Time With Care To gain reimbursement for prolonged services, you must document all time the physician spends face-to-face with the patient for outpatient coding, and all the unit/floor time the physician spends treating the patient in the inpatient setting. Without an actual minute value stated in the physician notes, prolonged service codes are not valid no matter how much time the physician actually spent. Time needn t be uninterrupted: The time you count toward prolonged services need not be continuous, although it should occur on the same date of service. The physician may consult with a patient in the hospital, spend 30 minutes discussing his condition, leave to perform regular rounds, and return to the original patient for another 40 minutes of counseling. The time spent with the patient both before and after the physician made rounds can contribute toward prolonged services. Give a reason: You must explain why the physician provided prolonged services, according to IOM instructions (Publication , Chapter 12, Section C), which state, to support billing for prolonged services, the medical record must document the duration and content of the E/M code billed. Simply noting that the physician spent an extra 42 minutes with the patient, for instance, is not adequate. You must prove, in the medical record, the medical necessity for the extra time spent. Don t Overuse Prolonged Services You must be careful not to use prolonged services codes too frequently. On average, you should report only once every 1,000 claims, while you should report only once every 100,000 claims, according to CMS estimated usage rates. Therefore, you should reserve prolonged service codes for truly time-consuming services, such as when a patient is noncompliant or requires special attention due to a mental or physical handicap, or if the surgeon must explain complex diagnoses, treatment options or substantial lifestyle changes to the patient. Deciding Between Prolonged Services and Time-Based E/M CPT specifies that if counseling and coordination of care consume 50 percent or more of an E/M visit, you may use time as the determining factor when selecting an appropriate E/M level. How, then, do you decide when to report prolonged services and when to use time to justify a higher E/M level? Example: Your physician conducts a 50-minute established outpatient visit during which he spends 35 minutes on coordinating care. Should you report 99215, or with ? Turn to History, Exam and MDM First Generally, you should assign E/M levels according to the key components of history, examination and medical decision-

5 making (MDM). Then, if the physician spends 30 minutes or more beyond the reference time of the chosen E/M level on counseling and coordination of care, you can use the prolonged services codes. If the physician spends fewer than 30 additional minutes beyond the reference time of the appropriate E/M level (as determined by history, exam and MDM) with the patient but counseling and coordination of care exceed 50 percent of the time allotted to the visit you may choose to code a higher E/M level based on time. Document and be honest: As long as the physician does not attempt to misrepresent the services he provides, he deserves reimbursement for additional time with a patient. Example: During an office visit, the physician tells the patient that he has a new diagnosis of colon cancer. Based on the components of history, examination and MDM, the visit warrants a level-two visit (99202). But the physician spends an additional 40 minutes (beyond the 20-minute reference time) discussing treatment options with the patient. In this case, you should report the visit (99202) and 40 minutes of prolonged services (99354). If the same patient presents for the same visit but requires only 20 additional minutes (again, beyond the 20-minute reference time for 99202) with the physician, you may not report prolonged services. But if the physician spends 30 minutes of a 50-minute visit (in other words, more than 50 percent of the visit) on counseling and coordination of care, you may use time as the key component when assigning the E/M level. Although the components of history, examination and MDM make the visit a level-two visit (99202), using time as the determining factor the physician can report (a level-three office visit). - Published on