Coverage Policies

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Current policies effective through April 30, 2024.

Use the index below to search for coverage information on specific medical conditions.

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Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 01/01/2005 Title: Prolonged Medical Services
Revision Date: 11/01/2023 Document: BI021:00
CPT Code(s): 99417, 99418, 99354, 99355, 99356, 99357, 99358, 99359, 99360
Public Statement

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.


Medical Statement

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:

 

99417

Prolonged outpt E/M service(s) time with or w/o direct patient contact beyond the req`d time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time (List separately in addition to the code of the outpt E/M svc) new code eff 1/1/2023

99418

Prolonged inpt or obs E/M service(s) time with or w/o direct patient contact beyond the req`d time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time (List separately in addition to the code of the inpt/obs E/M svc) new code eff 1/1/2023

99354

Prolonged service(s) in the outpt setting requiring direct patient contact beyond the time of the usual service; first hr (code revised eff 01-01-2021) (code deleted & replaced by 99417 eff 1/1/2023)

99355

Prolonged service(s) in the outpt setting requiring direct pt contact beyond the time of the usual svc; each add`l 30 min (code revised eff 01-01-2021) (code deleted & replaced by 99417 eff 1/1/2023)

99356

Prolonged service in the inpt or observation setting, requiring unit/floor time beyond the usual svc; first hr (code revised eff 01-01-2021) (code deleted & replaced by 99418 eff 1/1/2023)

99357

Prolonged service inpatient  (code deleted & replaced by 99418 eff 1/1/2023)

99358

Prolong service w/o contact

99359

Prolong serv w/o contact add

99360

Physician standby services


Reference

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.


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.