Prolonged Services Coding for Urgent Care

Coding for patient time: Information on the new prolonged services CPT codes in urgent care.

Q: The coding staff has relayed to me that we can now bill for times when my clinical staff must spend extra time with a patient. Is this true? What are the requirements for documentation?

A: Yes, there are two new Current Procedural Terminology (CPT) codes added in 2016 that allow you to bill for clinical staff that must spend time with the patient above and beyond what is considered to be the normal time. CPT codes  99415, “Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour (List separately in addition to code for outpatient Evaluation and Management service)” and 99416, “Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; each additional 30 minutes (List separately in addition to code for prolonged services)” are add-on codes to be used in conjunction with Evaluation and Management (E/M) codes 99201-99215. These codes may be reported for no more than two simultaneous patients and the physician or other qualified health care professional must be present to provide direct supervision of the clinical staff.

These codes cannot be used in conjunction with the prolonged service CPT codes 99354, “Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service)” or 99355, “Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (List separately in addition to code for prolonged service).” These prolonged services codes are reserved for the physician or other qualified health care professional.

Clinical staff must document the face-to-face time spent with the patient in order to bill the codes. The time does not have to be continuous, and time spent performing separately reported services other than the E/M service is not counted toward the prolonged services time. The Total Duration of Prolonged Services Table illustrates the correct reporting of prolonged services provided by clinical staff with physician supervision in the office setting beyond the initial 45 minutes of clinical staff time:

Total Duration of Prolonged Services         Code(s)

<45 minutes                                                    Not separately reported

45-74 minutes                                                 99415

75-104 minutes                                               99415, 99416

105-134 minutes                                             99415, 99416 X 2

To help better understand how the times above work with the office visit E/M codes, typical times for each E/M service are:

Code                                                 Time

99201                                                10 minutes

99202                                                20 minutes

99203                                                30 minutes

99204                                                45 minutes

99205                                                60 minutes

99211                                                5 minutes

99212                                                10 minutes

99213                                                15 minutes

99214                                                25 minutes

99215                                                40 minutes

It is advised, but not required, that start and stop times be used when the clinical staff spends face-to-face time with the patient. However, having that information, along with the progress of the patient during those times, leaves no doubt in the calculation of time for an auditor reviewing the medical record should the situation arise.

Q: We had an instance where, after having a minor laceration repair done, a patient was not feeling well so we kept her in one of our exam rooms to lie down. My staff looked in on her a couple of times and after about an hour, she felt better and was released. Can we bill for the time the patient spent in the exam room and for the time my staff looked in on her?

A: On January 1, 2016, the AMA did introduce new CPT add-on codes 99415 and 99416 to use when clinical staff spends a prolonged amount of time face-to-face with a patient. From your explanation above, you would want to make sure that the documentation supports face-to-face time with the patient. Just looking in on the patient for a minute or two every once in a while might not meet the time requirements for these codes.

Keep in mind that these codes must be used in conjunction with E/M codes 99201-99215 and follow the time requirement as outlined earlier in this article.

Q: Will Medicare pay for the new prolonged services CPT codes for clinical staff?

A: I believe that you are referring to CPT add-on codes 99415 and 99416. If you visit the Centers for Medicare and Medicaid Services website, https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx, you will find that these codes are indeed included on their physician fee schedule as active codes. The range of payment varies by jurisdiction, but at a glance, I have seen a reimbursement range for CPT code 99415 from $8.00-$12.00 and $4.00-$6.00 for CPT code 99416.

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