Beginning January 1, 2017, prolonged services without face-to-face contact are now separately payable under the Medicare Physician Fee Schedule. Prolonged services without face-to-face contact do not require face-to-face time with the patient, and may be rendered in an office, outpatient, hospital and nursing facility setting. Medicare requires these services “to be reported in relation to other physician or other qualified health care professional services, including E&M [evaluation and management] services, at any level.”
Previously, prolonged services without face-to-face contact could only be included for payment under a related face-to-face E&M service code. Practitioners were not permitted to bill a patient separately for services described by these codes, since they are Medicare-covered services and payment was included with the other billable services.
Now, these prolonged services are being reimbursed separately and may also “be reported on a different date than the primary service to which it is related”. However, they “must relate to a service or patient where [face-to-face] patient care has occurred or will occur and relate to patient management”. For example, a provider might use this code to represent an hour spent reviewing extensive medical records on a date prior to a scheduled upcoming new patient visit. Any entry in a medical record prior to a visit should describe the activity and time spent.
Prolonged services codes may not be used in collaboration with chronic care management (CCM), transitional care management (TCM), care plan oversight (CPO), anti-coagulant management, medical team conferences or online medical evaluations.
Providers should prepare explicit documentation describing each episode where this code is used to bill Medicare. Medical records must support medical necessity, time spent, and provide proof the prolonged service was not duplicated by other billed services, including E&M or global surgical services.
The Centers for Medicare & Medicaid Services (CMS) may issue additional guidance on these codes and their associated parameters and documentation requirements in the future. We will share information with providers as it becomes available.
Please contact your WCH account representative for more information about billing prolonged services without face-to-face contact.