Prolonged Services with Direct Patient Contact – Professional
Issue: #398 DEC2017
Blue Cross Blue Shield of North Dakota (BCBSND) will follow the current guidelines as written in the American Medical Association (AMA) CPT® book to determine whether a prolonged service code can be billed in addition to an E&M service or a 60-minute psychotherapy code.
Claims with prolonged services codes are reviewed individually with the medical record. Documentation must include:
- Amount of time billed (time must be spent in direct face-to-face contact with the patient and does not include unit time, nursing staff or administrative time)
- Medical appropriateness and necessity for the additional time
- Arrival and departure times
Prolonged physician services codes with direct patient contact (99354-99357) may be used when a physician provides a prolonged face-to-face service with a patient beyond the usual service/time in either an inpatient or outpatient setting. These codes are add-on codes (+) to the primary E&M service or 60-minute psychotherapy code provided and completed on the same date as the primary E&M service or 60-minute psychotherapy code, but the cumulative time need not be continuous.
CPT® codes 99354-99357 are used to report the total duration of face-to-face time spent in addition to the primary E&M service or 60-minute psychotherapy code and should be used only once per date of service. A minimum of an additional 30 minutes must be provided beyond the usual service time before 99354 or 99356 (first hour) can be billed.
A minimum of an additional 15 minutes must be provided before 99355 or 99357 (each additional 30 minutes) can be billed. A prolonged service less than 30 minutes is not separately reported.