Prolonged services payments on the rise

 

• 99354 (Prolonged service in an office or other outpatient setting with direct patient contact, first hour)

• 99355 (Each additional 30 minutes)

• 99358 (Prolonged service without direct patient contact, first hour)

• 99359 (Each additional 30 minutes)

 

Payment information: Medicare reimbursement for face-to-face prolonged services increased from a national average of $100.97 in 2016 to $131.15. Medicare began paying for non-face-to-face prolonged services as of January 1, 2017, reimbursing a national average of $113.41.

 

Quiz: Do you know your TCM codes?

 

Although payment for prolonged services went up, the bad news is that these services are also on the Office of Inspector General’s (OIG) Work Plan for 2017, an annual report that summarizes the OIG’s new and ongoing reviews and activities to reduce fraud, waste, and abuse related to various Department of Health and Human Services programs and operations. In the document, the OIG states that prolonged services are considered “rare and unusual.”

This means physicians who bill these services must have a clear and compelling reason to do so, says Raemarie Jimenez, CPC, CPC-I, vice president of membership and certification solutions at AAPC, an organization representing professional coders, billers, auditors, compliance professionals, documentation specialists and practice managers. “If you’re going to bill these services, there needs to be a summary of what you were doing to prolong that care,” she adds.

 

Further reading: Here's why high-levi E/M codes mean more money

 

With that said, many commercial payers continue to deny payment for these codes because they bundle them into the payment for the evaluation and management (E/M) service, says Kathleen Mueller, RN, CPC, president of AskMueller Consulting LLC, a healthcare consulting company. Rather than deny claims outright, some payers (including Medicare) may require additional documentation before rendering payment, says Mueller. They’re typically looking for proof of the time spent rendering the service and what tasks the physician performed during that time.

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