Table of Contents Previous Next

December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.56 Physician Evaluation and Management (E/M) Services : Prolonged Physician Services
Prolonged services involve face-to-face patient contact and may be provided in the office, outpatient hospital, or inpatient hospital settings. The face-to-face patient contact must exceed the time threshold of the following E/M procedure codes submitted for the date of service and be beyond the usual service.
The following procedure codes must be used for prolonged physician services:
Used in conjunction with the E/M procedure code to report the first hour of prolonged service and are limited to one per day.
Prolonged services in the inpatient setting involving face-to-face client contact that is beyond the usual service may be reimbursed when provided on the same day as an initial hospital visit (procedure codes 99221, 99222, 99223, 99251, 99252, 99253, 99254, and 99255) or a subsequent hospital visit (99231, 99232, 99233).
Prolonged physician services are denied when billed with critical care or emergency room visits billed with the same date of service.
Prolonged physician services and physician standby services without a face-to-face contact (procedure codes 99358, 99359, and 99360) are not a benefit of Texas Medicaid.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.