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Healthcare Fraud Shield's Latest Article: 2016 Changes-More Prolonged Visit Codes!

By Karen Weintraub posted 01-13-2016 08:22 AM

  
2016 Changes: More Prolonged Visit Codes!

 

In February 2013, Healthcare Fraud Shield wrote an article about the Current Procedural Terminology (CPT) Prolonged service codes, CPT 99354-99359.  These services are add-on codes affording providers extra reimbursement when rendering care that extends beyond the usual E/M (Evaluation and Management) service.  The American Medical Association has made some revisions and additions to this range of CPT codes. 
 
Prolonged Services Revisions
For example, the original descriptor of CPT code 99354 reads "Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; (List separately in addition to code for office or other outpatient Evaluation and Management service) " The revised 2016 description shows the following revisions highlighted in red: "Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Manage mentor psychotherapy service).[1]

As a result of this revision, you may see providers now billing CPT 99354-99355 with 90837 (Psychotherapy, 60 minutes with patient and/or family member).
 
Prolonged Services Additions
Effective January 1, 2016, the following two new codes were added [2]:

99415 Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour (List separately in addition to code for outpatient Evaluation and Management service)

99416 Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; each additional 30 minutes (List separately in addition to code for prolonged service)

What to look for:
  1. Use fraud detection software like PostShield™ to data mine for providers billing codes 99415-99416, 99354-99359 and target your outliers.
  2. Ensure medical records contain documentation of the time of the entire visit not just the prolonged service.
  3. Certify the medical records support and verify the service that took place during the extra time and was properly supervised by the physician or qualified health care practitioner ( codes 99415-99416).
Want to learn more about the 2016 code changes?  Attend Healthcare Fraud Shield's Complimentary Webinar on Tuesday, January 19, 2016 at 2PM EST.  Click HERE to sign up and for information regarding eligibility. 


REFERENCES:
[1,2] AAPC Coder
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