Value Your Time

George A. Sample, MD
Washington Hospital Center
Washington, D.C., USA

“We work not only to produce but to give value to time”—Eugene Delacroix

In all of our endeavors as healthcare practitioners, nothing we do is more important than caring for our patients at the end of their lives. Generally, we have expended our intellectual capabilities on healing and now must focus our humanism on the relief of pain and suffering for our patients and their families.

From a coding perspective, we tend to undervalue the time we spend with our patients and families. Many carriers recognize that this time is important, and if medically necessary, will make appropriate reimbursement.

One mechanism for capturing this is the proper use of prolonged service codes. For purposes of this discussion, only the two codes that address direct (face-to-face) patient contact in the inpatient setting will be considered (99356 and 99357).

There are nine points to consider when using these codes:

1. These two codes are add-on codes. They are used in addition to an already performed and documented evaluation and management (E/M) service (e.g., 99233, subsequent hospital visit [SHV]) on the same day.
2. These codes are time-based. The time allocated is as follows: 99356 is 30-74 minutes; 99357 is for each additional 30 minutes.
4. Prolonged service is the time spent beyond the Current Procedural Terminology (CPT) reference time for the E/M service. The CPT states that the reference time for 99233 is 35 minutes, 99232 is 25 minutes and 99231 is 15 minutes. Hence, the physician must spend no less than 65 minutes to bill both codes—99233 and 99356.
6. The time for prolonged services need not be continuous and it must represent the total time during the day.
8. Documentation is critical—the services provided and the duration of these services must be recorded.
9. Only certain inpatient E/M codes can be added upon hospital admission (99221-99223), SHV (99231-99233), consults (99211-99215), but not emergency department (ED) visits (99281-99285) nor critical care (99291/99292).
11. Time spent by non-physician providers (e.g., nurse practitioners, physician assistants, etc.) does not count toward your time when using prolonged service codes.
13. “If time is considered the key or controlling factor in choosing the level of E/M service, then the prolonged service codes (99354-99357) should only be used in addition if the service has exceeded 30 minutes beyond the highest level of E/M in the appropriate category.” (CPT 2004)
15. Avoid overusing these codes. The Centers for Medicare & Medicaid Services (CMS) believes that these codes should represent a very small fraction of your billing codes.

That’s the easy part! What is not easy is the arbitrary definition of “face-to-face.” If the family is in the unresponsive patient’s room and the intensivist is discussing end-of-life issues with them, would this be considered face-to-face? What is also variable among carriers/payors is if this discussion takes place in the unit or on the floor, is it reimbursable? Critical care physicians need to discuss this fine distinction with their carrier/payor. (Codes 99358/99359 are not discussed in this article, as they are not face-to-face, and are rarely reimbursed.)

However, an E/M may be chosen based solely on time spent in counseling the patient and family rather than history, exam, and medical decision making.

From CPT 2004:
“When counseling and/or coordination of care dominates (more than 50%), the physician/patient and/or family encounter (face-to-face time on the floor/unit or in the hospital), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. This includes time spent with parties who have assumed responsibility for the patient or decision making, whether or not they are family members. The extent of counseling and/or coordination of care must be documented in the medical record.”

Hence, if you spend 35 minutes on a given patient and at least 18 minutes for counseling/coordination of care, including the family, you can then bill 99233 (99232 for a 25 minute encounter, with more than 50% considered counseling). The counseling codes are not restricted to the highest level of code.

Counseling may include diagnostic studies/results, prognosis, risks and benefits, family encounters, patient education, etc., and may be done in the unit or on the floor, not necessarily at the bedside. Documentation should reflect the duration and discussion, e.g., “Over half of the 35 minutes spent with Mr. Smith and his family today was a discussion of …” As always, “he who has the gold, rules,” so check with your carrier/payor, as well.