24 May 2016

How to code Prolonged Services with Direct Patient Contact

Prolonged Services with Direct Patient Contact

           A physician or other qualified healthcare professional provides prolonged care involving direct patient contact that is provided beyond the usual service in either the inpatient or outpatient setting.  


Prolonged services are time-based codes,

      ·  Time must be documented. (This time does not need to be continuous).


      ·  Time should exceed the typical time of the E/M by at least 30 minutes.


      ·  They should indicate why the visit went beyond the usual services.


      ·  The start and end times of the visit shall be documented in the visit notes. 


Prolonged services in the office or outpatient setting:

 CPT 99354 - Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management service)


CPT +99355 - each additional 30 minutes 


Prolonged services in the inpatient or observation setting:

 CPT 99356 - Prolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient Evaluation and Management service)


CPT +99357 -  each additional 30 minutes 


Threshold time for codes 99354 and 99355 


Total Duration of Prolonged Services


Less than 30 minutes

    - Not separately reported

30-74 min (30 min - 1 hour 14 min)

    - 99354 x 1

75-104 min (1 hour 15 min-1 hour 44 min)

    - 99354 x 1 and 99355 x 1

105 min or more(1 hour 45 min or more)

    - 99354 x 1 and 99355 x 2



Example 1: An Established patient with autism comes into the office to see a neurologist. The neurologist performs a detailed history, a detailed physical exam, and medical decision-making of moderate complexity. Hence the E/M level is 99214 however, due to the patient’s inability to properly communicate with the neurologist, the visit takes 60 minutes instead of the typical 25 min.


The Typical E/M 99214 time given is 25 minutes and the total visit was 60 minutes, the remaining 35 minutes would be billed as prolonged care.



Under certain circumstances, we cannot bill prolonged services are,


·  In the case of prolonged office services, time spent by the office staff with the patient, or time the patient remains unaccompanied in the office cannot be billed.


·  If the total duration of direct face-to-face time does not equal or exceed the threshold time for the level of E&M service then the physician should not bill for prolonged services.



Prolonged services associated with E/M services based on Counseling & Coordination of care (Time)


    When an E&M is dominated by counseling and/or coordination of Care in the face-to-face encounter between the patient and physician in the office, then the E&M code is selected based on the typical time associated with the E&M code. 


    In those E&M services in which the code level is selected based on time, prolonged services may only be reported with the highest code level in that family of codes as the companion code.


Example: A physician provided a subsequent office visit that was predominantly counseling spending 60 min with the patient. The physician cannot code 99214 which has a typical time of 25 min and one unit of code 99354. The physician must bill the highest level code in the code family (99215 which has 40 min typical time) The additional time spent beyond this code is 20 minutes and does not meet the threshold time for billing prolonged services.




Prolonged services with non-face to face patient contact - See CPT 99358 and 99359