Family Discussions
As noted in my previous article on critical care services (March 2008, p. 18), family discussions can contribute toward counseling/coordination of care time when:
- The patient is unable or clinically incompetent to participate in discussions;
- Time is spent on the unit/floor with family members or surrogate decision makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment; or
- The conversation bears directly on the management of the patient.
Prolonged Care
A physician makes his rounds in the morning. He cares for a 72-year-old female with diabetes, end-stage renal disease, and hypertension. In the afternoon, he returns to find the family waiting with questions. He spends an additional 30 minutes speaking at the bedside with the patient and family. The additional afternoon effort may be captured as prolonged care if both services are documented appropriately.
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For inpatient services, CPT defines code 99356 as the first hour of prolonged physician services requiring face-to-face patient contact beyond the usual services (reportable after the initial 30 minutes). Code 99357 is used for each additional 30 minutes of prolonged care beyond the first hour (reportable after the first 15 minutes of each additional segment). Both codes are considered add-on codes and cannot be reported alone on a claim form; a primary code must be reported. Code 99357 must be used with 99356, and 99356 must be reported with one of the following inpatient service [primary] codes: 99221-99223, 99231-99233, or 99251-99255.
Prolonged care employs the concept of threshold time. This means total face-to-face physician visit time must exceed the time requirements associated with the primary codes by 30 minutes (e.g., 99232 plus 99356 = 25 minutes plus 30 minutes = 55 total face-to-face attending visit minutes). Accordingly, the physician must document the total face-to-face time spent during each portion of care in two separate notes or in one cumulative note. Be aware that this varies from the standard reporting of counseling and/or coordination of care time in that the physician must meet the threshold face-to-face-time requirements (see Table 1, left), making prolonged care services inefficient. When two providers from the same group practice split the threshold time (e.g., physician A provided morning rounds, and physician B spoke with the family in the afternoon), only one physician can report the cumulative service. To reiterate, 99356 must be reported on the same invoice as the primary visit code (e.g., 99232). Be sure once again to query payers, because most non-Medicare insurers do not recognize these codes. TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is on the faculty of SHM’s inpatient coding course.