Center to Advance Palliative Care

... ...
For Patients and Families
Partner
Sponsor
 
  Print this page
Views

CAPC Palliative Care Discussion Forum
Billing and Finance

Next Reply: Re:Billing for family meetings + prolonged services
Previous Message: RVUs for program development
Next Message: Social worker visit

Post Billing for family meetings + prolonged services
Author: dianeemeier [CAPC Faculty]
Date: Mar 19, 2009 11:38 am

We are hearing a widely variable experience from across the U.S. about acceptability of counting a face-to-face meeting with the patient's surrogate as a legitimate use of prolonged service (356/357) codes when the time for the underlying code. In addition some people are getting these codes paid, others report requests for documentation (the chart note) to back up the legitimacy of these codes, and some seem to get them all denied. Input and analyses on this subject would be greatly appreciated, preferably before AAHPM next week!

Diane E. Meier, MD, FACP
Director, Center to Advance Palliative Care
Director, Hertzberg Palliative Care Institute
Professor, Geriatrics and Internal Medicine
Mount Sinai School of Medicine
New York, NY

Replies: order by [Date] [Author] [Subject]
Re:Billing for family meetings + prolonged services (by LorenFriedman on 03/20/2009)
+ Re:Billing for family meetings + prolonged services (by dianeemeier on 03/20/2009)
+ Re:Billing for family meetings + prolonged services (by JulieP on 03/20/2009)
Re:Billing for family meetings + prolonged services (by dianeemeier on 03/20/2009)
Re:Billing for family meetings + prolonged services (by dianeemeier on 03/22/2009)
Re:Billing for family meetings + prolonged services (by dianeemeier on 03/23/2009)
See below from U Pitt's compliance office- the clearest explanation I have yet seen!

To address the issue - can prolonged care codes be billed for family visits in view of the change in the CPT code language effective Jan 2009: I asked UPP Compliance about this in a February email. This resulted in the below document being created by UPP Compliance. In summary - NO; at this time we are not billing prolonged care for family discussions. This is direction from UPP Compliance as noted in the below email:

"Be aware that there exists a distinct difference in the measurement criterion for inpatient prolonged services between the rules currently defined in the CMS Claims Processing Manual and the AMA CPT Manual 2009. CMS requires that the time-based measurement criterion for inpatient services is still “face-to-face” time with the patient whereas AMA’s CPT 2009 has changed this measurement criterion to “unit/floor” time. Both CMS and AMA agree that “face-to-face” time with the patient is the measurement criterion for office/outpatient services. All PSD must continue to enumerate inpatient prolonged services based on the direct “face-to-face” time. See the attached guidance document for complete details."


Dawn A. Moody, RN, CPC
Senior Medical Auditor
Division of General Internal Medicine
UPMC Health System
412-683-7649
moodyda@upmc.edu
Documentation and Coding for Prolonged Services

UPMC Physician Services Division Compliance Guidance Document
Documentation and Coding for Prolonged Services

NOTE: this announcement generally applies to UPMC Physician Services Division (PSD) billing providers (physicians and non-physician practitioners) that render and bill prolonged services add-on codes (CPT codes 99354 - 99357). However, this announcement also makes a general recommendation to document start and end times for all time-based services. If you do not render prolonged services or other time-based services, then you may ignore this announcement.

In July 2008, the Center for Medicare and Medicaid Services (CMS) made changes and clarifications to their rules regarding documentation and billing for prolonged services add-on codes. It is noted that these rules are fairly complex with regard to when these prolonged services (add-on) codes are legitimately billable and how the codes are selected. The complexity may be best evidenced by the fact that CMS publishes time threshold tables to aid providers with correct code selection. Because of the complexity of this coding, and for the two additional reasons discussed in the following paragraphs, it has been decided to publish a compliance guidance document on this subject.

Be aware that there exists a distinct difference in the measurement criterion for inpatient prolonged services between the rules currently defined in the CMS Claims Processing Manual and the AMA CPT Manual 2009. CMS requires that the time-based measurement criterion for inpatient services is still “face-to-face” time with the patient whereas AMA’s CPT 2009 has changed this measurement criterion to “unit/floor” time. Both CMS and AMA agree that “face-to-face” time with the patient is the measurement criterion for office/outpatient services. All PSD must continue to enumerate inpatient prolonged services based on the direct “face-to-face” time. See the attached guidance document for complete details

Another significant aspect of the CMS prolonged services rule is a requirement that the provider must document “start and end times” for the face-to-face visit with the patient in the medical record. Quoting from the rule: “…the start and end times of the visit shall be documented in the medical record along with the date of service.” The Compliance Office believes that the CMS requirement to document “start and end times” for prolonged services will likely migrate to other CMS rules for time-base services and other payers. We have already seen Highmark indicate a “start and end time” requirement (that does not exist in AMACPT Manual 2009) for a different time-based service in a specialized audit they are conducting. For these reasons, the Compliance Office urges providers to consider being proactive in documenting start and end times on all time-based services. With the prolonged services codes, documenting start and end times is an absolute requirement.

If you render and bill for prolonged services (CPT codes 99354 – 99357) the Compliance Office urges you to read the attached document and adhere to the documentation and coding instructions therein.
+ Re:Billing for family meetings + prolonged services (by rnielsen on 04/07/2009)
+ Re:Billing for family meetings + prolonged services (by cblizzard on 04/18/2009)
+ Re:Billing for family meetings + prolonged service (by jeffzesiger on 05/04/2009)

IMPORTANT: In order to post a new message or reply to an existing post in the discussion you must login. If you are not a registered member you may join here.
The statements posted in the forum section of capc.org are opinions expressed by website visitors and do not necessarily represent the viewpoints or positions of the Center to Advance Palliative Care(CAPC). CAPC is not responsible for the factual or legal accuracy of any of the statements posted.


For general questions about using the CAPCconnect™ palliative care discussion forum and lost username/password questions, contact Margaret.Schutz@mssm.edu