Specific criteria must be met to use prolonged services codes

While certain encounters may seem prolonged, CPT codes for prolonged services in inpatient and outpatient (e.g., office) settings can be reported only when specific criteria are met. This article will focus on how to code for prolonged services provided by physicians and other qualified health care professionals (OQHCP) in the office setting.

+ Designated add-on code, requires an appropriate primary code

There are two types of outpatient-based prolonged services:

1. Direct (face-to-face) +99354 and +99355
2. Non-direct (non-face-to-face) 99358 and +99359

For prolonged direct services:

• A minimum of 30 minutes above the time listed in the primary code is required (see table for time increments).
• Designated add-on codes can be reported only with the following primary service codes: 90837, 90847, 99201-99215, 99241-99245, 99324-99337, 99341-99350, 99483.
• All designated primary codes are time-based.
• Time spent by physician or OQHCP does not have to be continuous.
• Only face-to-face time with patient and/or family (including guardians) is counted.
• If reporting the primary service code based on time in lieu of key components, the time criteria in the highest code in the code set (e.g., 99215) must be met before prolonged service time can begin.
• Code 99355 must be reported with 99354.

For prolonged non-direct services:

• At least 30 minutes must be spent on a single calendar date (see table for time increments).
• Prolonged services include time spent performing non-direct services such as chart reviews.
• Prolonged services must relate to an upcoming encounter or a recent one.
• Codes may be reported alone (99358) or in conjunction with another service.
• Code 99359 must be reported with 99358.

Coding vignettes

An established patient and her mom present for an appointment to discuss management of the patient’s newly diagnosed type 1 diabetes. The visit lasts 75 minutes, of which over 50 minutes were spent on counseling and coordination of care.

Report CPT codes 99215 and 99354.

Coding tip: Because over 50% of the total face-to-face time was spent in counseling and coordination of care, time is the controlling factor. That means the time in the highest code in the code set must be met prior to starting prolonged time. The typical time for code 99215 is 40 minutes, which leaves 35 minutes of prolonged service time. Code 99354 is reported for 30-74 minutes of prolonged time.

In the morning, a physician sees a new adolescent patient for anxiety issues. The patient is still quite anxious after the appointment, so the physician tells the mom to return that day if needed. Later that day, the patient returns to discuss issues further and is referred to a specialist.

The physician spent 45 minutes with the mom and son in the morning, 35 minutes of which was spent in counseling. Later that day, the physician spent an additional 45 minutes in counseling/coordination of care.

Report CPT codes 99205 and 99354.

Coding tip: Because over 50% of the total face-to-face time was spent in counseling and coordination of care, time is the controlling factor in both encounters. Since the encounters are related and time spent does not have to be continuous, time from both encounters are added together. Remember that the time in the highest code in the code set must be met first prior to starting prolonged time. The typical time for a 99205 is 60 minutes, which leaves 30 minutes of prolonged service time. Code 99354 is reported for 30-74 minutes of prolonged time.

A developmental and behavioral pediatrician is scheduled to see a patient for the first time next week. Records from his school and primary care pediatrician are sent to assist in the initial exam. On the Friday before the appointment, the developmental and behavioral pediatrician spends roughly 45 minutes reviewing the records and writing a summary.

Report CPT code 99358.

Coding tip: Because the pediatrician performed more than 30 minutes of work on a single calendar date, non-direct prolonged services can be reported. Since 99358 is a stand-alone code, it can be reported on Friday before the initial encounter on Monday.

A developmental and behavioral pediatrician is scheduled to see a patient for the first time today. Records from his school and primary care pediatrician are sent to assist in the initial exam. In the morning prior to the appointment, the developmental and behavioral pediatrician spends roughly 20 minutes reviewing the records and writing a summary. The mom and patient then present to the office. The service will be reported based on key components (99204). A developmental test (96111) also is reported. The physician then spends 25 minutes after the encounter reviewing information the mom brought in from a previous developmental and behavioral pediatrician.

Report CPT codes 99204 (with modifier 25), 99358 (with modifier 25) and 96111.

Coding tip: The encounter is being reported based on key components, which was 99204. In addition, 96111 is reported for the developmental testing. The non-direct service can be reported with 99358 because the total time for that calendar date (20 minutes plus 25 minutes later in the day) is greater than 30 minutes. Remember that time spent does not have to be continuous if it is on the same calendar date.

Becky Dolan contributed to this article. For coding and billing questions, emailaapcodinghotline@aap.org.