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36.3.4.3 Prolonged Physician Services
Prolonged physician services may be rendered and are applicable in either an outpatient or inpatient setting.
Prolonged services may be provided in the office, outpatient hospital, or inpatient hospital settings and may involve direct (face-to-face) patient contact that is beyond the usual service and exceeds the time threshold of the E/M procedure code (see below) being submitted for the date of service.
Prolonged services in the inpatient setting involving direct (face-to-face) patient contact that is beyond the usual service are considered for reimbursement with the same date of service as an initial hospital visit (procedure codes 1-99221, 1-99222, 1-99223, 3-99251, 3-99252, 3-99253, 3-99254, and 3-99255) or a subsequent hospital visit (procedure codes 1-99231, 1-99232, and 1-99233).
Prolonged physician services are not considered for reimbursement in addition to critical care and/or emergency room visits submitted with the same date of service.
Procedure codes 1-99354 and 1-99356 should be used in conjunction with the E/M code to report the first hour of prolonged service and will be limited to one per day.
Procedure codes 1-99355 and 1-99357 should be used to report each additional 30 minutes and will be limited to a quantity of 3 units or one and one-half hours per day.
Prolonged services of less than 30 minutes duration should not be reported separately.
Prolonged physician services and physician standby services without face-to-face contact (procedure codes 1-99358, 1-99359, and 1-99360 are not benefits of the Texas Medicaid Program.
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