CPT 99354 – Prolonged physician service in the office or other outpatient setting, requiring direct (face-to-face) patient contact beyond the usual service – first hour (List separately in addition to code for office or other outpatient Evaluation and Management service)
The average reimbursement is in the range of $95.00, depending upon your region.
The Medicare Manual says:
The start and end times of the visit shall be documented in the medical record along with the date of service.
This code is one of many under-utilized codes in your office for many reasons. However, if you do the work and spend the prolonged time, face to face with the patient, document the progress note properly and provide the required medically necessary components, you deserve to use this code and get paid for your time.
Serious Illness Takes Serious Time
This code can be used for a seriously ill patient in your office, when you are spending a significant amount of time helping, while deciding the best course of action. This would include deciding to admit the patient to the hospital or sending the patient to the emergency room via a 911 call.
Usually, if you are spending over 40 minutes with the patient and have all of the criteria, you are going to document and bill for a 99215. However, if you end up spending any additional time, for example, over another 30 minutes with the patient, and your face-to-face total time counting all other services is 75 minutes or more, you may be entitled to capture the additional CPT code 99354.
Record Your Time!
It is prudent to report the start times and the ending times as well as the face-to-face time, in order to properly capture this code.
Overall, this really is not that difficult. For example, if you have a patient who comes into your office with an exacerbation of their COPD, you may start the patient on oxygen in your office while you perform your History, Physical and Medical Decision Making.
Keep Track of the Intensity of your Care
In the course of this you may order a nebulizer treatment for the patient and then leave the room to see another patient, you should document the time actually spent with the patient up to that point.
Once you return to the room the clock starts again. While speaking with the patient regarding how they feel after the nebulizer treatment, you may decide that they need an injection or another treatment. You document the time and then may have to leave the room to see another patient.
Once you return to the room, the clock starts again; so each time you decide on a treatment option for this patient, you continue to accrue time towards, not only the level CPT 99215 visit as the patient definitely will meet criteria for the intensity and medical necessity, you are potentially capturing the extra time needed to use the CPT 99354 code.
This code will enable you to be able to bill for the extra time you need to spend with the patient while you are stabilizing them, in order to decide if they can return home be transported to the hospital.
Many of us have the occasional patient who will use a significant amount of time in order for you to take proper care of them, to stabilize them and to decide whether the current problem they have can be handled from home or in the hospital.
Code Correctly for your Visit Too
If you provide the care, you deserve the code. That is why it is available in the first place. You owe it to yourself to maximize your revenue. Many providers will only bill this encounter as a CPT 99213 or CPT 99214. The reality is, if you do the work and properly document with the medical necessity in place, you can easily and comfortably bill for the appropriate code CPT 99215 and CPT 99354.
