Proper use of procedure code 99354 Prolonged Service

Here is a common Pediatricians office sample using Procedure Code 99354 Prolonged Physician Service with Direct Face to Face Patient Contact.

In this situation the patient was having breathing issues and came to the office for treatment. The provider documented that the patient was in the office for 40 minutes and had signs of wheezing and breathing issues. The provider remained in the room with the patient for 32 minutes during the office visit.

99214 - Office or outpatient E&M code 25 minutes face to face with patient and/or family
charge amount for 99214 $190.44
Allowed Amount by pts ins $126.28

99354 - Prolonged Office visit 30+ minutes face to face
charge amount for 99354 $200.00
Allowed Amount by pts ins $127.86

94640 - Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes
charge amount for 94640 $64.32
Allowed Amount by pts ins $0.00

J7603 - Albuterol
charge amount for J7603 $40.00
Allowed Amount by pts ins $.88

A7015 - Aerosol mask, used with the DME nebulizer
charge amount for A7015 $10.00
Allowed Amount by pts ins $1.41

A7016 - Dome and mouthpiece, used with small volumne ultrasonic nebulizer
charge amount for A7016 $15.00
Allowed Amount by pts ins $5.44

94664 - Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device
charge amount for 94664 $34.01
Allowed Amount by pts ins $0.00

94640 - Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes (for more than one inhalation treatment use modifier 76)
charge amount for 94640 $45.00
Allowed Amount by pts ins $18.05

Total Charge: $598.77
Total Allowed: $279.92

A call would be placed with UHC for the two denied codes to fix and reprocess:

94640 - IJ-THE NUMBER OF UNITS BILLED FOR THIS SERVICE APPEARS TO BE INCORRECT. IT EXCEEDS THE TYPICAL FREQUENCY PER DAY FOR THIS PROCEDURE CODE. WE'VE ADJUSTED THE UNITS FOR THIS PROCEDURE CODE AND CHARGE.

94664 - KW-WE PROCESSED THESE CHARGES USING A PROCEDURE CODE THAT MORE ACCURATELY DESCRIBES THE SERVICES PROVIDED.


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