Q. The coding staff has relayed to me that we can now bill for times when my clinical staff must spend extra time with a patient. Is this true? What are the requirements for documentation?
A. Yes, two new Current Procedural Terminology (CPT) codes added in 2016 by the American Medical Association allow you to bill for clinical staff members’ time spent with a patient above and beyond what is considered to be the usual amount of time. CPT codes 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),” and 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 services),” are add-on codes to be used in conjunction with evaluation and management (E/M) codes 99201 through 99215. These codes may be reported for no more than two simultaneous patients, and the physician or other qualified health-care professional must be in the clinic and immediately available to provide direct supervision of the clinical staff.
These codes cannot be used in conjunction with the prolonged- service CPT codes 99354, “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 management or psychotherapy service),” or 99355, “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; each additional 30 minutes (list separately in addition to code for prolonged service).” These prolongedservice codes are reserved for the physician or other qualified health-care professional.
Clinical staff must document the face-to-face time spent with the patient in order to bill the codes. The time does not have to be continuous, and time spent performing separately reported services other than the E/M service is not counted toward the prolonged-service time. Table 1 illustrates the correct reporting of prolonged services provided by clinical staff members with physician supervision in the office setting beyond the initial 45 minutes.
| Table 1. Total Duration of Prolonged Services | |
|---|---|
| Duration(mln) | Codes |
| <45 | Not separately reported |
| 45-74 | 99415 |
| 75-104 | 99415,99416 |
| 105-134 | 99415,99416 X 2 |
Table 2 will help you better understand how the times already discussed here work in conjunction with office-visit E/M codes. The table shows typical times as listed by CPT for each E/M service and how they affect reaching the threshold for CPT code 99415.
| Table 2. Effects of Add-On Code 99415 on E/M Codes | |||||
|---|---|---|---|---|---|
| E/M Code | Add-On Code 99415 | ||||
| Code | Time(min) | Total Staff Time (min) | Code | Total Staff Time (min) | Code |
| 99201 | 10 | <55 | NSR | 55-84 | 99415 |
| 99202 | 20 | <65 | NSR | 65-94 | 99415 |
| 99203 | 30 | <75 | NSR | 75-104 | 99415 |
| 99204 | 45 | <90 | NSR | 90-119 | 99415 |
| 99205 | 60 | <105 | NSR | 10-134 | 99415 |
| 99212 | 10 | <55 | NSR | 55-84 | 99415 |
| 99213 | 15 | <60 | NSR | 60-89 | 99415 |
| 99214 | 25 | <70 | NSR | 75-99 | 99415 |
| 99215 | 40 | <85 | NSR | 85-114 | 99415 |
| Table 1. Total Duration of Prolonged Services | |||||
It is advised, but not required, that start and stop times be used when clinical staff members spend face-to-face time with the patient. Noting actual time spent with the patient, along with the progress of the patient during those times, leaves no doubt about the calculation of time, should a recordauditing situation arise.
Q. We had an instance in which after having a minor laceration repair done, a patient was not feeling well, so we kept her in one of our examination rooms to lie down. My staff members looked in on her a couple of times, and after about an hour, she felt better and was released. Can we bill for the time the patient spent in the examination room and for the time my staff members looked in on her?
A. As already noted, new CPT add-on codes 99415 and 99416 are for use when clinical staff members spend a prolonged amount of time face-to-face with a patient. From your explanation, it appears that you would want to make sure that the documentation supports face-to-face time with the patient. Just looking in on the patient for a minute or two every once in a while is unlikely to meet the time requirements for these codes.
Keep in mind that these codes must be used in conjunction with E/M codes 99201 through 99215. Be sure to follow the time requirements outlined here in the preceding question. In addition, time spent with the patient in preparation for the procedure and performing the procedure will not count toward calculating the correct code. As noted in the previous answer, in order to use these codes, the minimum staff time spent with the patient beyond any time spent on the procedure is 55 minutes (with a code of 99201 or 99212). However, the minimum staff time for codes 99203 and 99214 is 90 minutes and 70 minutes, respectively.
Q. Will Medicare or other payors pay for the new prolonged-service CPT add-on codes 99415 and 99416 for clinical staff?
A.If you visit the CPT page of the website of the Centers for Medicare & Medicaid Services website, at https://www.cms.gov/apps/physician-fee-schedule/search/ search-criteria.aspx, you will find that these codes are indeed included on the Medicare physician fee schedule. The range of payment varies by jurisdiction, but reimbursements are in the general range of U.S.$8.00 to U.S.$12.00 for CPT code 99415 and U.S.$4.00 to U.S.$6.00 for CPT code 99416. For other payors, you will need to speak with them directly to obtain their reimbursement rates.
DAVID STERN, MD (Practice Velocity)
