What Is CPT Code 99354 on a Medical Bill?

Understanding CPT Code 99354

Current Procedural Terminology (CPT) codes are standardized five-digit codes used by healthcare providers to describe medical, surgical, and diagnostic services. These codes are fundamental in medical billing, enabling effective communication between providers and insurance payers, and ensuring services are accurately documented and processed for claims.

CPT code 99354 specifically represents a “prolonged physician or other qualified healthcare professional service.” This code indicates that a significant amount of additional face-to-face time was spent with a patient beyond the typical duration of a primary service. It serves as an important mechanism for healthcare providers to account for extended care when clinically necessary.

When This Code Applies

CPT code 99354 signifies a prolonged service that involves direct face-to-face patient contact, requiring 30 to 74 minutes of additional time beyond the usual service time. This code is classified as an “add-on” code, meaning it is never billed independently. It must always be reported in conjunction with a primary service code, such as an office visit or consultation code, to describe the complete encounter.

Prolonged service refers to time a healthcare professional spends directly with a patient beyond the typical duration of the primary evaluation and management (E/M) service. For instance, if a standard office visit is typically 30 minutes, and the provider spent an additional 45 minutes of face-to-face time, CPT code 99354 would be appropriate. This additional time must be medically necessary and thoroughly documented in the patient’s record.

The American Medical Association (AMA) removed CPT codes 99354 and 99355 on January 1, 2023. Prior to this deletion, CPT code 99354 was used for the first increment of prolonged face-to-face time beyond the typical primary service. For additional prolonged time beyond the first hour, CPT code 99355 was used for each subsequent 30-minute increment.

Examples of primary service codes that 99354 could be appended to included office or other outpatient visit codes (e.g., 99201-99205, 99212-99215) and office or other outpatient consultation codes (e.g., 99241-99245). The clinical rationale for the extended time, specific interventions during that period, and the patient’s response were crucial documentation points.

Impact on Your Medical Bill

The inclusion of a prolonged service code like 99354 on a medical bill generally meant an increase in the overall cost of the service. This code was designed to compensate healthcare providers for the significant extra time spent with a patient. Consequently, patients might have observed higher charges for visits where this code was applied.

Insurance coverage for prolonged service codes could vary significantly depending on the patient’s specific health plan, deductible, and copayment structure. Some insurance plans might have covered these prolonged services fully, while others might have applied higher out-of-pocket costs or even denied coverage if specific criteria were not met.

Patients could identify this code on their Explanation of Benefits (EOB) or medical bill, usually listed alongside the primary service code. If this code appeared, it was important for patients to review their EOB to understand how their insurance processed the charge. Questions regarding the charge or coverage should be directed to their insurance provider or the healthcare billing department for clarification.

Before their deletion, reimbursement rates for 99354 for the first hour of extended time typically ranged from $75 to $150, varying by region and provider. Patients should actively engage with their billing statements to ensure accuracy and understand their financial responsibility.

Key Points for Patients

Patients play an active role in understanding their healthcare services and associated billing. Clear communication with their healthcare provider about the duration and necessity of visits is always beneficial. Discussing the anticipated length of an appointment, especially for complex health issues, can help manage expectations.

Providers were required to maintain thorough documentation to justify the use of prolonged service codes. This documentation typically included the start and end times of the visit, along with a detailed explanation of the medical necessity for the extended time. Patients have the right to request information regarding the specifics of their visit that led to such a charge.

If a patient had questions or concerns about a charge involving a prolonged service code, it was appropriate to inquire with the provider’s billing office. Verifying the legitimacy of the charge involved asking for details about the prolonged time spent and the clinical reasons for it.

While CPT code 99354 and its counterpart 99355 are no longer used for most prolonged services, their former existence highlighted that certain medical encounters genuinely required substantial additional time. Understanding the principles behind such codes empowers patients to better comprehend their medical bills and advocate for themselves regarding healthcare costs.