Which Code Should I Use?

By W. Bruce Milliman, ND, and Eva Miller, ND (AMA - CPT/Editorial Panel/HCPAC, representing the AANP)

After the last two articles you may be asking yourself whether it is more appropriate to code for time via Evaluation and Management (E/M) codes or by using Prolonged Physician Service codes in CPT. We will try to flesh this out further in this last article on coding for time.

Prolonged service codes 99354 and 99355 are used in addition to Evaluation and Management (E/M) codes (99211-99215/99201-99205) when a physician provides a prolonged service directly to a patient in an outpatient setting that is beyond the typical examination. This means that the service attached to the E/M visit doesn’t make the visit more complex or require physical examination or history taking to be beyond the appropriate E/M service, but that it took longer than expected. These codes are for use only in conjunction with a performed E/M service (99201- 99215, 99241-99245, 99324 – 99337, 99341-99350) and can only be used after the time allotted for the designated E/M service has elapsed. For example, the patient is seen for a 99213 (15 min) plus an additional 30-74 minutes. Assuming appropriate care and documentation, this interaction is correctly coded as a 99213 + 99354.

When it comes to using E/M codes the CPT manual states “when counseling and/or coordination of care dominates (more than 50%) of the physician/patient and or family encounter, then time may be considered the key or controlling factor to qualify for a particular level of E/M service.”

If more than 50% of your visit is dedicated to counseling around a medical condition or coordinating care that makes your visit more complex or takes up greater than 50% of the allotted visit time, you can justify a higher E/M code as long as it is well documented and the other components such as history, review of systems and physical exam are also documented.

We suggest using what most accurately describes the service you provide and checking with insurance companies you are contracted with to see what method of coding for time is reimbursed.