Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Occasionally, a physician may need to spend extra time with a patient. In these situations, the physician may request additional compensation. QualChoice will periodically audit the use of this code.  If unusual patterns of use are noted, medical records will be requested to review required documentation.

1)    Prolonged physician service with direct (face-to-face) patient contact: Prolonged services involve direct face-to-face contact between the physician and the patient that is beyond the usual service in either the inpatient or outpatient setting. These codes should be used to report the duration of face-to-face time on a given date, even though the time is not continuous. Only that time in excess of the expected time investment of other E&M services billed on the same date should be counted.

a)    Prolonged Physician Services in the office or other outpatient setting

i)     For payment under 99354 to be justified, it must be clear from the clinical notes (if requested) that over 30 minutes of time were required by the clinical situation beyond that which would normally be spent on all other services billed on the same date.  Preventive medicine visits (99381-99397) do not have a specified time expectation.  Prolonged service codes will not be reimbursed on the same date as a preventive medicine visit.

ii)    Times spent by office staff with the patient and times the patient remains unaccompanied in the office are not to be counted.

iii)   For payment under 99355 to be justified,

(1)  99354 must also be billed and justified, based on over 60 minutes being spent beyond that which would normally be spent on the other services on the same date.

(2)  It must be clear from the clinical notes (if requested) that at least 15 additional minutes were required, beyond the time previously billed as 99354 (60 minutes) and other iterations of 99355 (at 30 minutes each).

b)    Prolonged Physician Services in the inpatient setting

i)     For payment under 99356 to be justified, it must be clear from the clinical notes (if requested) that over 30 minutes of time were required beyond that which would normally be spent on all other services billed on the same date.

ii)    Time spent waiting for test results, for changes in the patient’s condition, for the end of a therapy, or for the use of facilities cannot be billed as prolonged services.

iii)   For payment under 99357 to be justified,

(1)  99356 must also be billed and justified, based on over 60 minutes being spent beyond that which would normally be spent on the other services on the same date.

(2)  It must be clear from the clinical notes (if requested) that at least 15 additional minutes were required, beyond the time previously billed as 99356 (60 minutes) and other iterations of 99357 (at 30 minutes each).

2)    Prolonged physician service without direct (face-to-face) patient contact

a)    99358-99359: All of the activities described are included in the evaluation of levels of service for E&M coding.

b)    When billed on the same date as other face-to-face E&M services, these services will be rebundled into the other E&M service.

c)    When performed on a date when there was no face-to-face interaction with the patient, the nature and extent of the services must be documented in a medical record note, which will be reviewed prior to payment.

d)    These claims (without other E&M services on the same date) will initially deny with a request for medical records, and will be reviewed as a clinical edits appeal.

3)    Standby Services

a)    99360 - Standby services are not covered.

b)    This charge may not be billed to the patient, as no service was rendered to the patient; the service rendered was to the hospital.

Codes Used In This BI:

Addendum:

1.    Effective 12/01/2016:  Will deny without parent codes.  Will monitor use patterns and may request records to review required documentation.

2.    Effective 09/01/2017: Parent codes updated to match AMA CPT coding guidelines.

3.    Separated code ranges in the search box to make searchable.  Updated / revised codes 99354, 99355 and 99356 (eff 01-01-2021) and updated 99201 as deleted and replaced by 99202 eff 01-01-2021.

4.    Effective 01/01/2023 – Codes 99354-99357 were deleted & replaced by codes 99417 & 99418.