(Office or Other Outpatient Setting)
If the total direct face-to-face time equals or exceeds the threshold time for code 99354, but is less than the threshold time for code 99355, the physician should bill the evaluation and management visit code and code 99354. No more than one unit of 99354 is acceptable. If the total direct face-to-face time equals or exceeds the threshold time for code 99355 by no more than 29 minutes, the physician should bill the visit code 99354 and one unit of code 99355. One additional unit of code 99355 is billed for each additional increment of 30 minutes extended duration. Contractors use the following threshold times to determine if the prolonged services codes 99354 and/or 99355 can be billed with the office or other outpatient settings including domiciliary, rest home, or custodial care services and home services codes.
Threshold Time for Prolonged Visit Codes 99354 and/or 99355 Billed with Office/Outpatient
Code Typical Time for Code Threshold Time to Bill Code 99354 Threshold Time to Bill Codes 99354 and 99355
99201 10 40 85
99202 20 50 95
99203 30 60 105
99204 45 75 120
99205 60 90 135
99212 10 40 85
99213 15 45 90
99214 25 55 100
99215 40 70 115
99324 20 50 95
99325 30 60 105
99326 45 75 120
99327 60 90 135
99328 75 105 150
99334 15 45 90
99335 25 55 100
99336 40 70 115
99337 60 90 135
99341 20 50 95
99342 30 60 105
99343 45 75 120
99344 60 90 135
99345 75 105 150
99347 15 45 90
99348 25 55 100
99349 40 70 115
99350 60 90 135
Add 30 minutes to the threshold time for billing codes 99354 and 99355 to get the threshold time for billing code 99354 and two units of code 99355. For example, to bill code 99354 and two units of code 99355 when billing a code 99205, the threshold time is 150 minutes.
