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Prolonged service proficiency

From the October ACP Hospitalist, copyright © 2011 by the American College of Physicians

By Richard D. Pinson, FACP

Sidebars: Average time assigned per 2011 CPT® code to hospital E/M services Prolonged service codes (inpatient and subsequent observation) Examples Ask Dr. Pinson

For correct coding and optimum reimbursement, hospitalists must have a firm grasp on the nature and documentation requirements of prolonged evaluation and management (E/M) services. This challenging concept is often misunderstood, misapplied and underused. Failure to recognize, document and properly calculate prolonged services results in both underpayment and audit risks for non-compliance.

The coding and billing of prolonged services depend on the face-to-face time spent with the patient over and above the average time that the 2011 Current Procedural Terminology (CPT^®) codes assign to the usual E/M service (see box at bottom for average times).

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Face-to-face time for inpatient and subsequent observation services is defined by the 2011 CPT^® as “unit/floor time, which includes the time that the physician is present on the patient's hospital unit and at the bedside rendering services for that patient. This includes the time in which the physician establishes and/or reviews the patient's chart, examines the patient, writes notes, and communicates with other professionals and the patient's family.”

Under the description of Prolonged Physician Service with Direct (Face-to-Face) Patient Contact, the 2011 CPT^® states, “Codes 99356-99357 are used to report the total duration of unit time spent by a physician on a given date providing prolonged service to a patient.” The time may be continuous or discontinuous.

Code 99356 is assigned for the first 30 to 60 minutes of prolonged physician service in the inpatient setting (including subsequent observation services). Billing for less than 30 minutes of prolonged service is not allowed. Code 99357 is assigned for each additional 30 minutes after the first 60. Since a unit of time is only attained when the mid-point is reached, 99357 cannot be used until 75 minutes of prolonged service have been provided (60 minutes for 99356 plus an additional 15 minutes—the mid-point for 99357). See the “Prolonged Service Codes” and “Examples” boxes on page 11 for more details.

So how do you calculate prolonged service time?

• First, determine the total unit-time you spent with the patient during the day, whether the time was continuous or discontinuous.
• Next, look up the average time assigned by the 2011 CPT^® to the basic E/M service you rendered to the patient (see “Average Time” box, page 11).
• The billable prolonged service time will be the difference between the total time and the time assigned by the 2011 CPT^® to the basic E/M service provided (see “Examples” box, page 11).
• Document the time involved in the medical record.

In summary, keep track of the on-unit time spent on each patient, and document it. Bill as prolonged service the time spent above and beyond the average time assigned by the 2011 CPT^® to the basic E/M service provided on a given day.

Richard Pinson, FACP, is a certified coding specialist and co-founder of HCQ Consulting in Houston. This content is adapted with permission from HCQ Consulting.

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Average time assigned per 2011 CPT^® code to hospital E/M services

Initial inpatient

99221: 30 minutes

99222: 50 minutes

99223: 70 minutes

Subsequent inpatient (1/2 initial visit)

99231: 15 minutes

99232: 25 minutes

99233: 35 minutes

Subsequent observation* (same assigned times as “subsequent inpatient,” above)

99224: 15 minutes

99225: 25 minutes

99226: 35 minutes

*Prolonged service cannot be billed for initial observation services because the 2011 CPT^® does not assign an average time for them.

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Prolonged service codes (inpatient and subsequent observation)

99356: Technically 60 minutes, but applies to services between 30 and 75 minutes.

99357: Each additional 30 minutes beyond the first 60 minutes.

*Do not bill for less than 30 minutes of prolonged service.

**A unit of time is only attained when the midpoint is reached.

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Examples

Which codes would be assigned for 100 minutes of prolonged service time?

Code 99356 (for the first 60 minutes) and 99357 × 1 (for the next 40 minutes). While 99357 is used for each additional 30 minutes, the last 10 minutes does not reach the required midpoint (15 minutes) for assigning another code 99357.

A subsequent visit (code 99232) lasting 20 minutes is followed later in the day by 32 additional minutes reassessing the patient, reviewing old records and speaking with the family. What E/M codes can be assigned?

Code only 99232. The total time spent was 52 minutes. The average time assigned by the 2011 CPT© to code 99232 is 25 minutes. Subtracting 25 minutes from 52 minutes results in 27 minutes of additional on-unit time for the day. Since prolonged service cannot be billed for anything less than 30 minutes, code 99356 is not assigned.

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Ask Dr. Pinson

Q: I'm an internist-hospitalist. I often see patients in our hospital emergency department (ED), at the request of the ED attending, and admit them. My question regards coding for my ED consults when I decide NOT to admit the patient. The place of service is 23, but I'm not sure what CPT^® code or codes to use for the consultation, especially since the old consult codes were eliminated. The hospital does not have an observation unit, so observation codes can't be used. The ED physician will also bill the patient's insurance for his services, so my CPT^® code should differ from his. Very rarely, I'm the only doctor who sees the patient and it is my decision to send the patient home; the ED attending does not see the patient or bill. Does the code I use in this situation differ from the usual case in which the ED doctor sees the patient too?

A: CPT® codes are based in part on the location where services are provided. There are specific ED codes to be used by any provider who sees a patient in the ED, but payors will only pay an ED service to one provider on a given day. Unfortunately, if you evaluate a patient in the ED at the request of the emergency physician and the patient is discharged home, only one of you can bill for the ED services; there are no consultation codes for this. In theory, one might use code 99499 (Unlisted Evaluation), but reimbursement is unlikely.

If you are the only physician seeing the patient in the ED and send the patient home, you bill an ED CPT^® service code. If you see a patient in the ED who is then admitted, this service is included with your initial encounter code (Admission H&P)—either inpatient or observation services.

Observation services do not have to be provided in an observation unit (except perhaps in California where state regulations have been interpreted as requiring a separate dedicated unit for observation patients). A patient may be admitted in observation status to any hospital bed. If a patient's condition does not meet inpatient medical necessity criteria, Medicare and most other payors will not pay for the admission—but observation status may be used if the patient is unable to be discharged home. A hospital may be incur government sanctions and severe penalties for not assigning patients to the appropriate level of care.

Q: What is the hospital reimbursement rate difference for having a secondary diagnosis of overweight/obese versus morbid obesity, and is there a certain place these diagnoses need to be documented? I was also wondering if you could provide more information regarding hospital reimbursement for malnutrition as a secondary diagnosis.

A: Under the Medicare DRG payment system, hospitals may receive higher reimbursement for care of patients with a BMI less than 19 kg/m² or 40 kg/m² and over. The physician/ provider must also indicate a diagnosis that makes the BMI significant, or there will be no additional reimbursement. Even though morbid obesity is defined clinically as a BMI greater than or equal to 40 kg/m², a diagnosis of morbid obesity, obesity or simply overweight would meet the requirement for the higher reimbursement. For a patient whose BMI is less than 19 kg/m², the diagnosis might be emaciation, cachexia, malnutrition, underweight, anorexia, etc.

Whether the hospital actually receives a higher payment and the amount of that payment depend on many different factors in each case and cannot be determined until after discharge; the same is true with malnutrition. An attempt should be made in every case to obtain documentation of the BMI and the associated diagnosis, as well as malnutrition whenever present (especially if “severe”). Documentation anywhere in the medical record for the admission is acceptable.

In an unusual exception to Medicare rules, the BMI may be documented in the medical record by someone other than the physician, such as a nutritionist or nurse; the pertinent underlying condition must be documented by the physician.

E-mail us your coding questions.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated