that of working with an adult patient. In the real world of pediatric medical care, these conversations are separate from time spent managing the child’s complex medical problems.
The prolonged services codes are intended to be used in conjunction with office visit codes or inpatient visit codes (CPT codes 99201–99215, 99241–99245, 99301–99350). These office or inpatient visits are described as appropriately billed for counseling time if the time spent counseling is more than 50 percent of the physician-patient interaction. The total time for these codes goes up to 40 minutes, and this time most often is consumed doing the exam and reviewing charts and test results, so pediatricians should be able to rely on the prolonged service codes to bill additional time for counseling
There are specific codes for prolonged physician service with direct face-to-face contact (99354–99357), which are described as follows (Current Procedural Terminology [CPT], 2000):
Codes 99354–7 are used when a physician provides prolonged service involving direct (face-to-face) patient contact that is beyond the usual in either the inpatient or outpatient setting. This service is reported in addition to other physician service, including evaluation and management service. 99354 or 99456 are used to report a total duration of prolonged service of 30–60 minutes on a given date. 99355 or 99357 are used to report each additional 30 minutes beyond the first hour.
These descriptions suggest that the codes should cover the extended communication necessary in pediatric care. Although the CPT lists these as billable in 30-minute increments with a maximum of 3 hours total, the reality is that they are relatively poorly reimbursed (and often denied outright by payers) relative to surgical procedures or physical exams, even though they represent a large percentage of time spent by physicians in caring for children with advanced illness. The COG PIs reported as follows: 40 percent do not even bill these codes because experience has shown they will not be reimbursed; 60 percent do bill them, and of these, 25 percent are rejected and 75 percent reimbursed (many are not able to collect information about how much is collected), with practices receiving a median of $91.00 for the first hour of service (range $47.00 to $144.00) and a median of $75.00 for an additional half-hour (range $21.00 to $142.00).
The codes for prolonged physician service without direct (face-to-face) patient contact are 99358 and 99359. These services are described as appropriate for non-face-to-face time spent by physicians providing “evaluation and management services at any level” and billable for continuous or discontinuous time in 30- minute increments with no stated maximum. However, the Health Care Financing Administration considers these two codes to be bundled into office and hospital visits. Thus most payers do not