Explore This IssueMay 2015
Prolonged Care Reminders
Prolonged care codes exist for both outpatient and inpatient services.
- 99356: Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour.
- 99357: Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; each additional 30 minutes.
Both of these codes are considered “add-on” codes and cannot be reported without a primary service. In this case, the appropriate “inpatient” E/M code (e.g. 9922x, 9923x, 9925x) represents the “primary” service. Code 99356 is reported during the first hour of prolonged services, beyond the initial encounter time, and 99357 is used for each additional 30 minutes of prolonged care beyond the first prolonged care hour. Only one unit of 99356 may be reported per patient per physician group per day, whereas multiple units of 99357 may be reported in a single day.
The CPT definition of prolonged care varies from that of the Centers for Medicare and Medicaid Services (CMS). CPT recognizes the total duration spent by a physician on a given date, even if the time spent by the physician on that date is not continuous; the time involves both face-to-face time and unit/floor time.5 CMS only counts direct face-to-face time between the physician and the patient toward prolonged care billing. Time spent reviewing charts or discussion of a patient with house medical staff that does not involve direct face-to-face contact with the patient, or waiting for test results, for changes in the patient’s condition, for end of a therapy, or for use of facilities cannot be billed as prolonged services.6 This contradicts policy for C/CC services and makes prolonged care services an inefficient practice method.
Medicare also identifies “threshold” time (see Table 3). The total physician visit time must exceed the time requirements associated with the “primary codes by a thirty”-minute threshold (e.g. 99221 + 99356 = 30 minutes + 30 minutes = 60 minutes threshold time). The physician must document the total face-to-face time spent in separate notes throughout the day or in one cumulative note. The latter method is a more realistic option for physicians. When two providers from the same group and same specialty provide services on the same date (e.g., physician A saw the patient during morning rounds, and physician B spoke with the patient/family in the afternoon), only one physician can report the cumulative service.4 As always, query payers for coverage, because some non-Medicare insurers do not recognize these codes.—CP