CPT code 99354, CPT 99354, 99354, 99354 CPT code

CPT Code 99354 | Description, Billing Guidelines, Reimbursement, Modifiers & Examples

CPT code 99354 is a medical procedural code that falls under the “Prolonged Service With Direct Patient Contact according to the American Medical Association (AMA).

More time is devoted to psychotherapy or an outpatient assessment and management service by the healthcare provider (other than 99202-99205 or 99212-99215). Enter CPT 99354 for the first hour of additional time.

Before beginning an extended period, ensure that the time in the highest code in the code set can meet.

The typical 99205 completion time includes a 30-minute buffer. Many people have reported problems with error code 99354 between 30 and 74 minutes.

The patient will see a developmental and behavioral pediatrician the following week after waiting a few days.

Records from his school and primary pediatrician can provide as supplements to the initial exam.

On the Friday before the appointment, a developmental and behavioral pediatrician reviews each child’s file and writes a summary in about 45 minutes.

 Until recently, doctors could only bill this code using E/M codes, but many insurance companies are now reimbursing it with routine service codes.

As a result, clinical psychologists, psychiatrists, marriage and family therapists, licensed clinical social workers, and LCSWs can return using the 99354 CPT code. 

CPT code 99354 can use for up to 30-74 minutes of additional treatment time. However, you cannot bill 99354 because 99354 cannot bill at any specific time. A minimum of 30 minutes can add to the time of the original procedure code.

For mental health professionals, 99354 can usually bill in conjunction with 90837 or 90847. 90837 lasts 60 minutes, whereas 90847 lasts 50 minutes. 

Both procedure codes 99354 and 99355 can use in conjunction with each other for different 30-minute sessions. Session times can increase by at least 30 minutes to accommodate the additional time required by procedure code 99354.

The time factor spent by physicians is the noticeable point for billing guidelines of CTP code 99354.

If the extended session lasted longer than expected, 99355 would charge. 99354 is heavily reliant on the insurance company and can not always reimburse. When this occurs, the fee schedule frequently allows for reimbursement under 90837.

99354 CPT Code Description

The CPT manual describes CPT code 99354 as: “Prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service; first hour.”

CPT code 99354 describes an add-on CPT code for extended service. It is one of the 99354 to 99359 add-ons that comprise the comprehensive services subgroup of principles. This service can only bill using the correct procedure code.

Even though non-medical personnel can now submit 99354 for review, this does not imply that it is universally accepted.

If you see clients for more extended periods than expected, billing the 99354 CPT code is a great way to get paid fairly. We can handle this for you using our billing service. 

Some insurance companies can pay for the expenses, but this is not always the case, while others are curious. We can inquire on your behalf before an extended session if you bill with us.

If you want to submit claims with the CPT 99354, you must have one of the following credentials:

  • Clinical social workers who are licensed (LCSW)
  • Individuals who hold a professional counseling license (LPC)
  • Marriage and Family Therapists with a state license (LMFT)
  • Specialists in the field of psychology (Ph.D. or PsyD)
  • Psychiatrists are specialists (MD)

A doctor’s outpatient medical care extends beyond the standard first hour of treatment.

This service’s billing information includes any level of designated evaluation and management services and any additional physician service provided during the same session.

For any supplies or procedures given or performed during this period, use the appropriate codes.

Doctors can use 99354 and 99355 codes to determine how much time they spent with their patients on that day, even if they were not continuous.

Even if the time spent was not constant, a doctor providing E/M services to a patient could use CTP code 99354 to determine the time involved on that particular date.

Even if the physician’s time on a given date is not continuous, both codes will only use once. Aside from the specifics of a CPT code, the primary payment criterion is the service’s necessity.

Billing for higher-level evaluation and required management services would be medically incorrect. Extended service codes can include the addition of evaluation and management services at any level. 

Billing Guidelines For CPT 99354

CPT code 99354 can be assigned based on how much time can spend in person with the patient on a specific date. This could have occurred at any point during that day.

 The time for standard service refers to the standard operating procedure (SOP) for the evaluation and management service’s average active period (CPT code).

The quantity of documentation will not use to calculate the cost of a particular service level.

Despite the patient being in the doctor’s office for four hours, the doctor only provided forty minutes of direct F2F service.

Because the total time spent in direct F2F contact fell short of the required time, the doctor cannot bill for comprehensive services. The CPT 99213 can use in this instance.

In an office setting, neither staff members’ time with patients nor patients’ time alone in an office can bill. Medical staff cannot review charts or discuss patients without direct face-to-face contact, and the time spent doing so cannot quantify.

A delay of fewer than 15 minutes between the start and end of service does not require reporting as a separate incident.

For comprehensive services, when time is of the essence, CPT codes 99354 to 99357 will use in addition to E/M service at the highest level.

If a time estimate can link to the “typical/average time linked to the E&M code,” it should not be “rounded” up or down to a higher level. 

Companion codes for EMS services can only be of higher code levels, which can change over time. Additionally, any physician or qualified NPP direct F2F evaluation and management service must meet or exceed the CPT E/M code threshold plus 30 minutes (typical/average CPT E/M code time plus 30 minutes).

CPT code definitions require proper and sufficient documentation of direct face-to-face time with a patient. A medical review does not require the submission of medical records along with a bill for additional services.

However, the length, scope, and content of any extended services billed as medically necessary evaluation and management services would include in medical records. 

How To Use Modifier 25 For CPT Code 99354

The modifier used for CTP code 99354 is modifier 25. Modifier 25 can use to make an evaluation and management bill easier to understand on the day of the procedure.

In addition, this form can sometimes use to document an E/M service provided by one doctor on the same day as another procedure. 

On the procedure day, a significant, separately identifiable E/M service provided by the same doctor can document this procedure modifier 25 can use to make a bill for E/M services easier on the day. 

Doctors frequently use modifier 25 as an efficient way to CTP code 99354 services related to evaluation and management (E/M). An E/M service and process can document in the medical file to support a claim. The modifier 25 can use for the best E/M service.

 CPT guidelines designate the E/M services provided by the same physician as a 25 modifier because they are significant and individual basis easily recognizable.

The doctor’s exam met the modifier 25 criteria for being significantly different from any other services provided that day.

Prepayment review of claims with E/M codes and modifier 25 should not occur unless Medicare contractors meet the following conditions: “Conducted a specific medical review process and discovered that a person or group had a high usage rate for modifier 25.”

We examined each case to ensure that the modifier 25 can not use incorrectly. The 25 modifier allows us to code physician services with the highest level of specificity possible while also ensuring that the doctor can appropriately compensate for those services. 

Even if modifier 25 is used exclusively in coding and reimbursement, physicians must still adequately document the need for E/M services, regardless of the subsequent procedure (s).

Therefore, physicians and their coding and billing staff must collaborate to produce the most precise and clear E/M claims supported by appropriate medical documentation.

Reimbursement

An additional 1 hour and 45 minutes can be reimbursed for CPT code 99354 for a diagnostic interview.

In 2020, the payout rate for CPT Code +99354 was $132.09.

CPT Add-On Code +99354 will reimburse at a rate of $129.10 in 2021.

Example 1

The direct F2F services required 65 minutes for CPT code 99213, which specifies a doctor’s office visit. CPT codes 99354 and 99211 are both billed for a single unit.

Example 2

Visit a domiciliary or rest home. A physician performed CPT code 99327, which required 140 minutes of direct face-to-face contact (including the visit). The physician bills CPT 99327, CPT 99354, and a single unit of CPT 99355.

Example 3

Most of a doctor’s time in an office visit (direct F2F) with an established patient can spend on counseling. The physician provides codes 99354 and 99215.

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