Healthcare Fraud Shield’s Latest Article: Changes to Prolonged Services

20 Oct

 

Healthcare Fraud Shield wrote an article in 2013 explaining the use of prolonged service codes. Well, back in 2013 we said time is money and in 2020, the times have changed.  Just a refresher – what are Prolonged Services? Prolonged Service codes are used when the healthcare professional performs “beyond the usual service.”1 Providers are able to bill for three types of prolonged service codes:

1.   Prolonged service with direct patient contact,

2.   Prolonged services without direct patient contact,

3.   Providers providing direct supervision of clinical staff delivering a prolonged service    Providers billing these codes typically receive added reimbursement in addition to payment for the base evaluation and management code. As a result, these services may be prone to fraudulent and/or abusive billing.

So what’s new in 2021 for Prolonged Services?

 Effective January 1, 2021, there is a new Current Procedural Terminology (CPT) code, 99417.2 Per the AMA, CPT 99417 is defined as a: Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes of total time (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services).

In addition to the new code, changes were made to existing prolonged services. For example:

CPT 99354 and 99355 underwent some changes as well:

·     Both codes are described now as prolonged services as opposed to “prolonged evaluation and management or psychotherapy service(s)”

·     Office was removed or other outpatient was removed from the description and now it’s just outpatient setting

·     The codes can no longer be reported with new patient or established patient evaluation and management (e/m) codes (99202-99215)

·     99354 is to be used in conjunction with 90837, 90847, 99241-99245, 99324-99337, 99341- 99350, 99483 only

The American Academy of Family Physicians3 provided an example of the use of 99417:

“the multiple current codes will become a single CPT code, 99417, which you can bill in 15-minute increments when total time exceeds a level 5 visit. So, a visit of 55-69 minutes with an established patient would require 99215 plus a single 99417 prolonged services code. A visit of 70-84 minutes with an established patient would take a 99215 plus two 99417 prolonged services codes, and so on”

What to look for?

·     Any outlier billing patterns related to prolonged services by specialty, diagnoses, line of business and more

·     What percentage of a provider’s overall claims contain these codes?

·     Check policies and verify with your respective plans how time is to be calculated.4

 If you have any questions, feel free to email us at info@hcfraudshield.com.

REFERENCES:

1,2 AMA CPT Book

3 AAFP

4 CMS – Prolonged Services

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