Q: What is the correct way to code prolonged services when their evaluation and management (E/M) is time-based?
A: When a provider is billing E/M codes based on time, there is a specific way that the guidelines tell us to bill prolonged services.
Codes 99354-99355 are reported in the office or other outpatient setting when a provider performs prolonged service(s) involving direct patient contact provided beyond the usual E/M or psychotherapy service.
Companion codes include office outpatient visit codes (99201-99205, 99212–99215) and outpatient consultation codes (99241–99245).
Codes 99356-99357 are used in the hospital or nursing facility setting to report the total time duration spent by a provider at the bedside and on the patient’s floor or unit in addition to an E/M code on a given date. Companion codes include initial hospital care (99221-99223) and subsequent hospital care 99231–99233) codes.
Code 99355 or code 99357 are add-on codes used to report each additional 30 minutes beyond the first hour, depending on the place of service. Prolonged service of less than 15 minutes beyond the first hour is not reported separately. For this series of codes, it is not required that the time spent by the physician or other qualified health care professional on that date be continuous.
The time for usual service refers to the typical/average time units associated with the companion E/M service as noted in the CPT code.
When billing an E/M service by time (i.e., the counseling and/or coordination of care represents more than 50% of the total time with the patient) in a face-to-face outpatient encounter (or floor time inpatient encounter) between the provider and the patient, the E/M code is selected based on the typical time associated with the code levels. The time must meet or exceed the specific CPT code billed and shouldn’t be rounded to the next higher level.
Further, in E/M services in which the code level is selected based on time, you may only report prolonged services with the highest code level in that family of codes as the companion code.
CPT coding guidelines may differ from commercial payer guidelines, so be sure to contact your payers to see if they have different rules.