CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Prolonged services (prolonged evaluation and management) coding and reimbursement

This policy documents BCBSRI coding guidelines and reimbursement criteria for CPT prolonged service add-on codes (99354-99359, 99358-99359, 99415-99416) and related billing rules for BlueCHiP for Medicare and Commercial Products. It applies to participating providers submitting claims to Blue Cross & Blue Shield of Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyProlonged services (prolonged evaluation and management) coding and reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective Date07/11/2019

Next Review DateN/A

Key ActionDo not submit prior authorization; include supporting documentation (start/end times or total time and evidence of physician direct contact) with claims to avoid suspension for individual consideration.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

99354-99359primary prolonged service CPT range covered when documentation met

TU modifiermodifier/payment for extended child/adolescent psychiatric interview

Claims suspendclaims suspend for individual review requiring documentation

99415-99416prolonged clinical staff service codes covered but not separately reimbursed

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Coverage Criteria for Prolonged Services

Coverage criteria for prolonged services

Covered when ALL of the following documentation and coding requirements are met. Claims for prolonged services (CPT 99354-99359) will automatically suspend for individual consideration review and must include supporting documentation at time of submission.

ALL of the following

Documentation must include start and end times of the visit OR the total time spent having direct patient contact and non-face-to-face time (excluding telephone encounters).
Documentation must reflect the physician time spent having direct contact, including any additional non-face-to-face time (excluding telephone encounters).
Sufficient medical record documentation must support that the provider personally furnished the prolonged service time with the patient as specified in the CPT code definitions.
If codes 99358/99359 are reported on a different date of service than the primary service, the documentation must include medical records supporting the prolonged service and the service to which it is related.
The documentation should meet coding guidelines for the primary E/M service; if time is used to select the E/M level, the record must indicate when counseling was the dominant service provided.

Coding and reporting requirements for the prolonged service add-on codes are met (time-based add-on codes require that the primary E/M service have a typical or specified time published in CPT).

ALL of the following

Prolonged services of less than 30 minutes on a given date should not be reported separately (minimum reportable duration).
Do NOT report with the following services: Prolonged services are not appropriate to bill with the following categories: Preventive Medicine (99381-99397), Emergency Medicine (99281-99285), Critical Care (99291-99292), Neonatal ICU (99295-99298), anticoagulation management (99363-99364), care plan oversight (99339-99340, 99374-99380), medical team conference (99366-99368), certain patient management/CCM/TM services (99487-99489, 99495-99496), telephone encounters, or when time is solely staff time in the office.

ALL of the following

CPT codes 99415 and 99416 (prolonged clinical staff service) are covered but not separately reimbursed.
Prolonged service CPT codes are reported as add-on codes in addition to the primary E/M or psychotherapy service as specified in CPT (eg, 99354 first hour in office/outpatient; 99355 each additional 30 minutes; 99356/99357 inpatient/observation; 99358/99359 before/after direct care).
Behavioral health special case: For behavioral health services provided to children under age 18, extended psychiatric diagnostic interviews longer than 75 minutes may be billed using modifier TU with 90791/90792 per applicable coding guidance.

ALL of the following

Supporting documentation must be filed with the claim at the time of submission for individual consideration review.

ALL of the following

It is not appropriate to bill prolonged services for time counted toward other services with no upper time limit or for services specifically excluded by CPT guidance.

Codes, Durations, and Modifiers

Prolonged service codesCPTCovered

99354	Office/outpatient prolonged service; first hour (add-on)
99355	Office/outpatient prolonged service; each additional 30 minutes (add-on)
99356	Inpatient/observation prolonged service; first hour (add-on)
99357	Inpatient/observation prolonged service; each additional 30 minutes (add-on)
99358	Prolonged service before and/or after direct care; first hour
99359	Prolonged service before and/or after direct care; each additional 30 minutes
99415	Prolonged clinical staff service; first hour (covered but not separately reimbursed)
99416	Prolonged clinical staff service; each additional 30 minutes (covered but not separately reimbursed)

Minimum reportable duration (office)

Minimum reportable duration (office)Prolonged service of less than 30 minutes on a given date should not be reported separately.

RationaleTime-based add-on codes require the primary E/M service to have a typical or specified time; short durations (<30 minutes) do not meet add-on reporting criteria.

Related codesOffice/outpatient prolonged add-on codes: 99354 (first hour) and 99355 (each additional 30 minutes).

Extended psychiatric interview (under 18)

Modifier and codesUse modifier TU with 90791 or 90792 for extended psychiatric diagnostic interviews for members under 18.

Duration threshold

Provider Billing and Claim Handling

Prior Authorization

Prior authorization not required; claims suspend and require supporting documentation

Prior authorization is not required. Claims filed for prolonged services (CPT 99354-99359) will automatically suspend for individual consideration review; supporting documentation must be submitted with the claim at time of filing. Documentation must include start and end times or total time, evidence of physician direct contact (including additional non-face-to-face time, excluding telephone), records linking the prolonged service to the primary service, and for codes 99358/99359 any supporting records when reported on a different date. Sufficient documentation must show the provider personally furnished the prolonged service time.

Submit supporting documentation with the claim at time of submission.
Include start and end times or total time and evidence of physician direct contact.
Document non-face-to-face time (telephone encounters excluded).
If 99358/99359 are on a different date, include medical records supporting the prolonged service and the related primary service.
Ensure documentation shows the provider personally furnished the prolonged service time.

Definitions and Supporting Documentation

Prolonged service — definition

DefinitionProlonged services are add-on codes reported when a physician or other qualified healthcare professional provides direct patient contact beyond the usual service time of an E/M or psychotherapy service; may include additional non-face-to-face time related to the encounter.

ScopeApplies in inpatient, observation, office, and other outpatient settings when documentation supports the additional time.

Coding noteTime spent performing separately reported services or services described by other CPT codes with no upper time limit is not counted toward prolonged service time.

Date flexibilityCodes 99358/99359 may be reported on a different date than the primary service but require supporting medical records linking the prolonged service and primary service.

Supporting documentation — required elements