Bill Medicare Correctly for Prolonged Services — Part 1

TrailBlazer Health Services recently evaluated a sampling of Medicare claims, looking at documentation for prolonged services with direct patient contact (CPT codes 99354–99357), as well as the associated evaluation and management (E&M) services. It concluded it had paid in error $82.50 of every $100 paid for prolonged services and associated E&M services in these claims from practices in Texas, New Mexico, and Colorado.

The most common documentation errors associated with prolonged services are below. Avoid these errors to keep your claims from being denied.

  • Documentation did not substantiate that the time spent beyond the associated E&M service level was reasonable and necessary to meet but not exceed the patient’s needs or treat the presenting problem.
    • Generic or template statements, such as “prolonged education” or “discussed alternative treatments” lacked sufficient detail to support the time spent, the need for additional time beyond the usual encounter, or that information was customized to the individual patient’s conditions.
    • Documentation did not indicate an acute or substantial change in the patient’s stable condition and/or plan of care to warrant the time element reported.
  • Documentation did not clearly identify the time was spent in direct (face-to-face) contact with the patient.
  • Documentation included references to indirect time, such as telephone calls, office staff performing procedures, and chart review, as part of the overall time element reported.
  • Documentation lacked start and end times of the direct (face-to-face) contact.
  • Time spent performing other services (i.e., non-E&M procedure codes) was included in the time calculation for reporting prolonged services.
  • Time thresholds for reporting the prolonged service and the E&M service together were not met.

In addition, TrailBlazer denied payment for associated E&M services for lack of medical necessity.

TrailBlazer has provided a detailed case study (scroll down) that exemplifies many of the shortcomings for which a prolonged services claim might be denied.

Need help with coding and documentation? TMA Practice Consulting can help with a comprehensive coding and documentation review and/or training — and you can earn continuing medical education credits. TMA Practice Consulting also now offers Coding & Documentation Check-ups, an abbreviated review of claims coding and medical record documentation performed by a professional coder and auditor to provide a glimpse into a physician’s coding techniques. For details, or to speak with a consultant, call (800) 523-8776, or email

Published March 28, 2012 

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