Prolonged Services Codes Update

Dear Providers:

Health Share, Jackson Care Connect, Columbia Pacific CCO including our CareOregon Advantage Plans, have experienced increased overutilization and billing of Prolonged Services codes (CPT codes 99354-99355, 99358-99359).  Therefore, we will be conducting oversight of the use of these codes starting February 1, 2019.

Beginning February 1, 2019, claims submitted that contain Prolonged Services codes will require chart notes that substantiate the medical necessity of the service.  Payment for these codes will be dependent on documentation that the time spent beyond the usual service was medically necessary and appropriate as well as meeting general coding standards.  While some entities (e.g. providers conducting child abuse evaluations in specialized settings) may deliver prolonged services on a frequent basis, the routine use of these codes is generally not medically necessary.  We have seen increasing routine usage of these codes, without evidence of clinical necessity, as part of standard billing practice.  Given that in most cases the need for extended time cannot be anticipated, the use of a Prior Authorization process to address this overutilization is not practical.

In cases where the billing of Prolonged Services is believed to be medically necessary and appropriate, chart notes will be required with the claim to substantiate the medical necessity.  Claims received without documentation will be denied.  Claims received with documentation will be reviewed by CareOregon for medical necessity to determine whether payment is appropriate. 

Sincerely,

Douglas Luther, MD
Senior Medical Director, CareOregon

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