Prolonged Service Add-on codes now apply to outpatient mental health

The add-on codes for prolonged services, 99354 and 99355 are now applicable to face-to-face outpatient mental health as well as for E/M codes.  Previously these codes were only reimbursable if used with E/M codes.
+99354 – Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service, first hour
+99355  –  Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service, each additional 30 minutes
Previously CPT code 90837 was the longest code to report individual psychotherapy.  The 90837 indicates 60 minutes.  If a doctor or therapist saw a patient longer than one hour there was no way to report the additional time.  With this new rule, add-on codes can be used to report the additional time.
For example, if a psychologist spends 90 minutes with a patient face to face for individual psychotherapy they would report the 90837 and the 99354.  If they spent two hours and thirty minutes, it would be reported using the 90837, 99354, and one unit of 99355.
It is important that the patients chart is noted with the time spent with the patient.  Even though these add-on codes can be applied to outpatient mental health it doesn’t mean that all insurances or all plans will cover the add-on codes.  Also, prior authorization rules would still apply as well.
They have also created two new add-on prolonged service codes.  +99415 and +99416 are to report prolonged face to face services performed by a physician, NP or PA.  These prolonged service codes start at services > 45 minutes.
Note:  The + in front of a CPT code indicates that it is an add-on code and that a primary CPT code must be used.


10 Responses to “Prolonged Service Add-on codes now apply to outpatient mental health”

  1. Lisa Marshall Says:

    Thank you for the info, I always benefit from your emails.
    These codes would apply to many of my mental health providers, any suggestions as to how we can easily get these codes added to their fee schedules?

  2. Gina Henderson Says:

    I am having difficulty with Medicare paying for Prolonged physician attendance in the office. They pay the Visit, 99354 and only 3 units for 99355. They say it needs a modifier but I have tried every modifier nothing works. Any help would be appreciated

  3. solutionsmedicalbilling Says:

    No easy suggestions for obtaining fee schedules. Medicare posts theirs on line but most do not. You would have to contact each carrier to request that information.

  4. Barbara Griswold, LMFT Says:

    My understanding is that these Prolonged codes were added in January right after the 2013 CPT codes went into effect. However, my experience talking to therapists around the country is that insurance plans may completely reject or not reimburse for these codes, particularly if used by non-physician providers (since we don’t typically use codes that start with 99), so I don’t get the sense they are too helpful. Do you have experience getting reimbursed by insurance plans for these codes, and if so, which plans? Also, if you do use these, would you use them only with a 90834 or 90837, since they are add-on codes and need to be added to something? That is, would you bill a 2 1/2 hour session as a 90837, +99354, +99355?

  5. solutionsmedicalbilling Says:

    We actually have not yet billed any but have a therapist group that is planning on trying. I agree that most insurance plans will not consider this as a covered service but I don’t have anything to base that on yet. We will keep everyone posted if we receive responses back with these codes and the 90837.

    • Sara Sickels Says:

      I would like know what you have learned since this post. I have several counselors who would so happy if they could get paid for the extra time they are spending with their clients.

      • solutionsmedicalbilling Says:

        We have not billed any yet. We provided the information to our providers but none of them have billed it out yet.

  6. Barbara Griswold, LMFT Says:

    You said these codes were now reimbursable for outpatient mental health services, not just E/M codes. Can you give me your source for this? I want to back up any statements I make in my blog

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