Office or Outpatient Prolonged Services

Published 06/14/2018

This electronic Comparative Billing Report (eCBR) focuses on providers who have submitted claims for Office or Outpatient Prolonged Services Evaluation and Management (E/M) Services (CPT codes 99354-99357). eCBR information is one of the many tools used to assist individual providers to become proactive in addressing potential billing issues and performing internal audits to ensure compliance with Medicare coverage guidelines.

For your personalized eCBR results on Office or Outpatient Prolonged (E/M) Services (CPT codes 99354-99357) log into our eServices portal. An eCBR will be available for providers who have at least 10 claims in history for this CPT code family during the time period selected.   

An overview of the criteria for billing Prolonged E/M Physician Services with Direct Patient Contact is being made available for your review for clarification purposes.  Medicare allows for coverage of prolonged provider services when billed on the same day by the same physician, or qualified Non-Physician Practitioner (NPP), as the companion evaluation and management codes. You may count only the duration of direct face-to-face contact with the patient (whether the service was continuous or not) beyond the typical/average time of the visit code billed. Although the codes allow for usage with psychotherapy services, for the purpose of this eCBR only claims with evaluation and management companion codes were considered. See Table 1 for descriptions of the codes.

Table 1: Summary of CPT Prolonged Services Codes

Type
CPT Code
Description
Office/Outpatient
99354
Prolonged evaluation and management or psychotherapy service, when requirements for direct face-to-face patient contact, for the first hour, beyond the usual service in the office or other outpatient setting is billed on the same day by the same physician or qualified NPP as the companion evaluation and management codes.  Usual service time refers to the typical/average time units associated with the companion evaluation and management service as noted in the CPT code.
Office/Outpatient
99355
Following the first hour of prolonged services (outpatient), each additional 30 minutes of direct face-to-face patient contact is reported by CPT code 99355.
In-Patient
99356
Prolonged evaluation and management or psychotherapy service, when requirements for direct face-to-face patient contact, for the first hour, beyond the usual service time in the inpatient setting is billed on the same day by the same physician or qualified NPP as the companion evaluation and management codes.
In-Patient
99357
Following the first hour of prolonged services (inpatient), each additional 30 minutes of direct face-to-face patient contact is reported by CPT code 99357.

Required Companion Codes
Prolonged services codes 99354-99357 are not payable unless they are accompanied by the companion codes listed here.  For detailed information on companion codes, please visit the ‘E/M Help Center’ as shown below in the Resources section of this article.

  • Companion E/M codes for CPT 99354 are: 99201-99205, 99212-99215, 99324-99328, 99334-99337, 99341-99345, or 99347-99350
  • Companion E/M codes for CPT 99355 are 99354 in conjunction with one of its required E/M codes
  • Companion E/M codes for CPT 99356 are: 99221-99223, 99231-99233, 99304-99306, 99307-99310, and 99318
  • Companion E/M codes for CPT 99357 are 99356 in conjunction with one of its required E/M codes

Methods:
The metrics reviewed in this eCBR are the proportion of billing for each CPT code in the E/M grouping with comparisons to peers within the nationwide Railroad Retirement Board Specialty Medicare Administrative Contractor (RRB SMAC) Jurisdiction. This report is an analysis of Medicare Part B claims extracted from the Palmetto GBA data warehouse. The analysis shows the portions of your claims for CPT codes 993541-99357 at levels compared to your peers in the RRB SMAC.

Example of eCBR Results from eServices:

eCBR Lookup New Patient Office Visits

Please be aware that the information contained within this eCBR is not intended to be punitive or an indication of fraud. Rather, it is intended to be proactive communication that will assist you in identifying potential billing issues and help you with performing a self-audit of your conformity with Medicare guidelines.

For more information about this or other eCBRs, please call our Provider Contact Center at 888-355-9165, and select Option 5. Customer Service Representatives are available Monday through Friday, from 8:30 a.m. - 4:30 p.m. in all time zones with the exception of Pacific Time. This service is available from 8:30 a.m. - 4 p.m. PT.

Educational Resources:
CMS Resources

Palmetto GBA Railroad Medicare Resources