Office or Outpatient Care Prolonged Services: Description and Companion Codes

Prolonged services may be billed for direct, face-to-face outpatient services. The service must be on the same day of service as the primary service and performed by the same provider. The CPT code 99354 is for prolonged service, office or outpatient, first hour. After the first hour, submit CPT code 99355 for each additional 30 minutes.

In determining whether prolonged services can be billed and to determine the prolonged services codes that are allowable, you may count only the duration of direct face-to-face contact with the patient which is beyond the typical/average time of the visit code billed (whether the service was continuous or not).

In the outpatient or office setting, time spent by office staff with the patient, or times the patient remains unaccompanied in the office cannot be used to determine the time of prolonged services.

These codes require submission of an outpatient evaluation and management code as a companion code. Documentation for prolonged services must contain enough information to substantiate the medical necessity of the prolonged service and the start and end times of the visit must be documented.

Prolonged Outpatient E/M Codes

Tables below include descriptors of companion codes that may be submitted as pre-requisites for billing office or outpatient prolonged services.

New Patient Office/Outpatient Codes (CPT Codes 99201-99205)

Established Patient Office/Outpatient (CPT Codes 99212-99215)

Domiciliary, Rest Home, or Custodial Care Services- New Patient (CPT Codes 99324-99328)

Domiciliary, Rest Home, or Custodial Care Services- Established Patient (CPT Codes 99334-99337)

Home services- New Patient (CPT Codes 99341-99345)

Home Services- Established Patient (CPT Codes 99347-99350)

References

• Medicare Claims Processing Manual (PDF, 1.1 MB), Publication 100-04, Chapter 12, section 30.6.15.1.D