How Claims Can Avoid Getting Denied for Prolonged Services CPT Code 99354, 99355 for Payments

You can definitely avoid and eliminate claims denials and non-payment only if you equip your self with enough knowledge on how to do it right. How to appropriately report the Prolonged Services codes.

Here are your Codes for Prolonged Services

  • 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 codes for office or other outpatient Evaluation and Management services).
    • Do not report in conjunction with 99415, 99416
  • 99355 Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service; each additional 30 minutes
    • (List separately in addition to codes for office or other outpatient Evaluation and Management services).
    • Use 99355 in conjunction with 99354.
    • Do not report in conjunction with 99415, 99416
  • 99356 Prolonged physician service in the inpatient setting requiring direct (face-to-face) patient contact beyond the usual service; first hour
    • (List separately in addition to codes for office or other outpatient Evaluation and Management services).
  • 99357 Prolonged physician service in the inpatient setting requiring direct (face-to-face) patient contact beyond the usual service; each additional 30 minutes
    • (List separately in addition to codes for office or other outpatient Evaluation and Management services).
  • 99358 Prolonged E&M service without direct (face-to-face) patient contact; first hour
    • (List separately in addition to code(s) for other physician service(s) and/or inpatient or outpatient Evaluation and Management service).
  • 99359 Prolonged Evaluation and Management service without direct (face-to-face) patient contact; each additional 30 minutes
    • (List separately in addition to code(s) for other physician service(s) and/or inpatient or outpatient Evaluation and Management service).

Prolonged Services Coding and Billing Tips:

  • These codes are not stand-alone codes;
  • Prolonged services are only billable if the total duration of direct face-to-face service by the doctor which includes the visit has exceeded the timed Evaluation and Management service by a minimum of 30 minutes;
  • You can only bill the prolonged services codes if the total duration of all physician or qualified NPP direct Face-to-face service including the visit equals or exceeds the threshold time for the evaluation and management service the physician or qualified NPP provided;
  • that is the typical or average time associated with the CPT Evaluation and Management code plus 30 minutes;

Evaluation and Management EM Codes

99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.

If you spend for 60 minutes face-to-face with the patient, you can report prolonged service code CPT 99354 in addition to 99213

99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.

99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.

If the Provider spent 50% of his/her time counselling the patient with over-all total times spent face-to-face for 105 minutes; you report 99215, 99354, 99355 (each additional 30 minutes)

More of Prolonged Services Coding and Billing Tips:

  • If it did not exceed the timed level of Evaluation and Management service by at least 30 minutes, the Physician may NOT bill for prolonged services
  • Time spent by office staff with the patient, or time spent by the patient inside the exam room waiting for the Physician or NPP is not billable for prolonged services
  • Evaluation and Management services that require prolonged clinical staff time and may include face-to-face services by the physician or other qualified providers should be reported with the new codes 99415 or 99416
  • For Evaluation and Management services in which the code level is selected based on time, you may only report prolonged services with the highest code level in that family of codes as the companion code. in which the code level is selected based on time, you may only report prolonged services with the highest code level in that family of codes as the companion code.
  • Prolonged services codes DO NOT need a Modifier to be appended on the Evaluation and Management Code (99213-99215)
  • CPT Codes Prolonged Services 99354-99355 are not stand alone codes
  • Codes are used based on Place of Service (take note of this)

Companion Required Codes for Prolonged Services

  • The companion evaluation and management codes for 99354 are the Office or Other Outpatient visit codes (99201-99205, 99212-99215)
  • The companion codes for 99355 are 99354 and one of the evaluation and management codes required for 99354.

Let’s look at this coding illustration:

Total Prolonged Services:
less than 30 minutes Can not reported separately
30-74 minutes (30 min to 1 hr 14 min) 99354 x 1 unit
75-104 minutes(1 hr 15 min to 1 hr 44 min) 99354 x 1 unit and 99355 x 1 unit
105 minutes or more ( 1 hr 45 min or more) 99354 x 1 unit and 99355 x 2 units or more for each additional 30 minutes

Documentation Requirements for Evaluation and Management Prolonged Services

  • Document the Medical Necessity of the evaluation and management direct face-to-face encounter;
  • Document that the encounter was a direct face-to-face encounter performed by the Physician or NPP;
  • Document the start to end times of the visit for billed prolonged evaluation and management services

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CPT is a trademark and owned by the American Medical Association – AMA

References: CPT Assistant Publication October 2015, Medicare Website and other Commercial Payers Guidelines and Policies, CPT Coding Books 2018 and 2019, ICD-10 Code Books 2018 and 2019

Useful Links:

  • https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/mm5972.pdf (revised in 2017)
  • https://www.oxhp.com/secure/policy/prolonged_services.pdf (Oxford Policy)



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Author: Pinky Maniri

Ms. Pinky, as she is fondly called - is a Reputable Professional Consultant and Expert in Practice Administration, Medical Billing, Coding, Health Information Technology, Insurance Credentialing and Compliance for Physician Offices. Well-educated with a Degree in Computer Systems Engineering and a background in Clinical Nursing and Small Business Management. Her professional mission is to make sure her clients/physicians maximize reimbursement while they remain compliant with the current rules, changes, guidelines and policies. Read More About Ms. Pinky here and See what Other's say about her Expertise Testimonials

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