| West Virginia Oncology Society |
With the discontinuance of consultation codes for services provided January 1, 2010 and after,
there have been many questions concerning the use of prolonged care procedure codes. In order
to use a prolonged care code (99354 and 99355 for outpatient or 99356 and 99357 for facility), a
provider must document the total of the face-to-face time (including the visit) spent with the
patient to support the use of the procedure code. The Centers for Medicare & Medicaid Services
(CMS) Internet Only Manual (IOM) Publication 100-04, Chapter 12, Section 30.6.15 discusses the
use of prolonged services and provides a chart showing the face-to-face threshold times required.
This section also provides examples of when a prolonged care code is and is not appropriate.
Providers choose the procedure code that most accurately reflects their services in one of two
ways. Providers can document the level of the history, exam, and medical decision making. In
order to evaluate whether a prolonged care code is appropriate, the documentation must show
the total face-to-face time (including the visit) the physician or non-physician practitioner spent
with the patient (does not have to be continuous) and that total time is used to determine
whether a prolonged care code is appropriate. Time the patient spends away from the provider
does not count toward the use of a prolonged care procedure code.
The other way a provider may choose a procedure code is based on time when more than 50% of
the face-to-face time in the office or time spent on the floor or unit in a facility is spent in
counseling and/or coordination of care. When assessing whether a prolonged care code is
appropriate, again only the total face-to-face time (including the visit) spent with the patient is
used. When assessing the use of prolonged care codes when time has been used to document
the service, then only the highest level of service in the family of codes may be used. In a facility,
time spent on the floor or unit in providing the service is not counted toward the use of the
prolonged care codes. Time spent in gathering information from the family or discussing the
medical decision options with the family not in the presence of the patient does not count toward
the use of prolonged care codes.
there have been many questions concerning the use of prolonged care procedure codes. In order
to use a prolonged care code (99354 and 99355 for outpatient or 99356 and 99357 for facility), a
provider must document the total of the face-to-face time (including the visit) spent with the
patient to support the use of the procedure code. The Centers for Medicare & Medicaid Services
(CMS) Internet Only Manual (IOM) Publication 100-04, Chapter 12, Section 30.6.15 discusses the
use of prolonged services and provides a chart showing the face-to-face threshold times required.
This section also provides examples of when a prolonged care code is and is not appropriate.
Providers choose the procedure code that most accurately reflects their services in one of two
ways. Providers can document the level of the history, exam, and medical decision making. In
order to evaluate whether a prolonged care code is appropriate, the documentation must show
the total face-to-face time (including the visit) the physician or non-physician practitioner spent
with the patient (does not have to be continuous) and that total time is used to determine
whether a prolonged care code is appropriate. Time the patient spends away from the provider
does not count toward the use of a prolonged care procedure code.
The other way a provider may choose a procedure code is based on time when more than 50% of
the face-to-face time in the office or time spent on the floor or unit in a facility is spent in
counseling and/or coordination of care. When assessing whether a prolonged care code is
appropriate, again only the total face-to-face time (including the visit) spent with the patient is
used. When assessing the use of prolonged care codes when time has been used to document
the service, then only the highest level of service in the family of codes may be used. In a facility,
time spent on the floor or unit in providing the service is not counted toward the use of the
prolonged care codes. Time spent in gathering information from the family or discussing the
medical decision options with the family not in the presence of the patient does not count toward
the use of prolonged care codes.
What's New. . . . .
| MEDICARE UPDATE CLARIFICATION ON THE USE OF PROLONGED CARE PROCEDURE CODES |