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The American Medical Association (AMA) recently shared Evaluation and Management (E/M) coding updates for the year 2023. The last E/M coding updates occurred in the year 2021, which allowed physicians to choose between medical decision-making and time based reporting for their services. New E/M coding updates will extend the 2021 guidelines changes to other places of service and codes, specifically inpatient/observation. 2023 coding updates will be centered around code sets, including inpatient and observation care services, consultations, prolonged services, emergency department services, home services and nursing facility services. Prolonged services are getting yet another overhaul. So let’s understand recent coding updates and overall prolonged E/M codes for 2023.

Prolonged E/M Coding Updates for 2023

  • Deletion of Prolonged Services E/M codes 99354-99357: The American Medical Association (AMA) is deleting prolonged codes 99354, 99355, 99356, and 99357. CPT code range 99354 – 99357 were face-to-face prolonged care codes that could be used with office/outpatient codes or inpatient, observation or nursing facility.
  • Revision of guidelines for Prolonged Services E/M codes 99358, 99359, 99415, and 99416: Non-face-to-face prolonged care codes 99358 and 99359 remains the same when the services are performed on a date other than a face-to-face visit. There is a long list of services which may not be reported on the same date, and you may never double count time spent, so there a long list of services for which CPT don’t include the time of non-face-to-face prolonged care when you’re reporting these other care management services. CMS is proposing to give codes 99358 and 99359 a status indicator of invalid, which would make them non-payable for Medicare patients. Prolonged E/M coding updates for 2023 also include revising the editorial comments for prolonged clinical staff codes 99415 and 99416. These codes are also not payable by Medicare.
  • Revision of Prolonged Services E/M code 99417 and guidelines: Existing prolonged care code 99417 which currently may be used only with 99205 and 99215 will be reported with outpatient consult code 99245, home visit codes 99345 and 99350, and cognitive assessment code 99483 in 2023.
  • Establishment of Prolonged Services E/M code 993X0 and guidelines: The AMA is developing a new prolonged care code, which is not released in its recent update. The placeholder code that the AMA is using is 993X0 for additional 15-minute increments of time with or without patient contact to be used with hospital codes 99223, 99233, and 99236, and consult code 99255, and nursing facility codes 99306 and 99310.
  • The prolonged services codes may now only be used with the highest level code in the category or subcategory. Also note that in the Medicare proposed rule, they are developing additional HCPCS codes for prolonged care, and will not recognize the CPT codes.

Prolonged E/M Codes for 2023

Deleted Codes 99354, 99355, 99356, and 99357

Evaluation and Management (E/M) codes 99354, 99355 have been deleted. For prolonged evaluation and management services on the date of outpatient service, home or residence service, or cognitive assessment and care plan, you can use 99417. Evaluation and Management (E/M) codes 99356, 99357 have been deleted. For prolonged evaluation and management services on the date of an inpatient or observation or nursing facility service, you can use 993X0.

CPT Codes 99358 and 99359

E/M codes 99358 and 99359 are used when a prolonged service is provided on a date other than the date of a face-to-face evaluation and management encounter with the patient and/or family/caregiver. Codes 99358, 99359 may be reported for prolonged services in relation to any evaluation and management service on a date other than the face-to-face service, whether or not time was used to select the level of the face-to-face service.

This service is to be reported in relation to other physician or other qualified health care professional services, including evaluation and management services at any level, on a date other than the face-to-face service to which it is related. Prolonged service without direct patient contact may only be reported when it occurs on a date other than the date of the evaluation and management service. For example, extensive record review may relate to a previous evaluation and management service performed at an earlier date. However, it must relate to a service or patient which (face-to-face) patient care has occurred or will occur and relate to ongoing patient management.

Codes 99358 and 99359 are used to report the total duration of non-face-to-face time spent by a physician or other qualified health care professional on a given date providing prolonged service, even if the time spent by the physician or other qualified health care professional on that date is not continuous. Code 99358 is used to report the first hour of prolonged service on a given date regardless of the place of service. It should be used only once per date.

Prolonged service of less than 30 minutes total duration on a given date is not separately reported. Code 99359 is used to report each additional 30 minutes beyond the first hour. It may also be used to report the final 15 to 30 minutes of prolonged service on a given date. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.

Do not report 99358, 99359 for time without direct patient contact reported in other services, such as care plan oversight services (99374- 99380), chronic care management by a physician or other qualified health care professional (99437, 99491), principal care management by a physician or other qualified health care professional (99424, 99425, 99426, 99427), home and outpatient INR monitoring (93792, 93793), medical team conferences (99366-99368), inter professional telephone/Internet/electronic health record consultations (99446, 99447, 99448, 99449, 99451, 99452), or online digital evaluation and management services (99421, 99422, 99423).

CPT Codes 99415 and 99416

Codes 99415, 99416 are used when an evaluation and management (E/M) service is provided in the office or outpatient setting that involves prolonged clinical staff face-to-face time with the patient and/or family/caregiver. The physician or other qualified health care professional is present to provide direct supervision of the clinical staff. This service is reported in addition to the designated E/M services and any other services provided at the same session as E/M services.

Codes 99415, 99416 are used to report the total duration of face-to-face time with the patient and/or family/caregiver spent by clinical staff on a given date providing prolonged service in the office or other outpatient setting, even if the time spent by the clinical staff on that date is not continuous. Time spent performing separately reported services other than the E/M service is not counted toward the prolonged services time.

Code 99415 is used to report the first hour of prolonged clinical staff service on a given date. Code 99415 should be used only once per date, even if the time spent by the clinical staff is not continuous on that date. Prolonged service of less than 30 minutes total duration on a given date is not separately reported. When face-to-face time is non-continuous, use only the face-to-face time provided to the patient and/or family/caregiver by the clinical staff.

Code 99416 is used to report each additional 30 minutes of prolonged clinical staff service beyond the first hour. Code 99416 may also be used to report the final 15-30 minutes of prolonged service on a given date. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.

Codes 99415, 99416 may be reported for no more than two simultaneous patients and the time reported is the time devoted only to a single patient. For prolonged services by the physician or other qualified health care professional on the date of an office or other outpatient evaluation and management service (with or without direct patient contact), use 99417. Do not report 99415, 99416 in conjunction with 99417. Do not report 99415 and 99416 in conjunction with 99417.

CPT Codes 99417

Code 99417 is used to report prolonged total time (i.e., combined time with and without direct patient contact) provided by the physician or other qualified health care professional on the date of office or other outpatient services, office consultation, or other outpatient evaluation and management services (i.e., 99205, 99215, 99245, 99345, 99350, 99483). Code 993X0 is used to report prolonged total time (i.e., combined time with and without direct patient contact) provided by the physician or other qualified health care professional on the date of an inpatient evaluation and management service (i.e., 99223, 99233, 99236, 99255, 99306, 99310).

Prolonged total time is time that is 15 minutes beyond the time required to report the highest-level primary service. Codes 99417, 993X0 are only used when the primary service has been selected using time alone as the basis and only after the time required to report the highest-level service has been exceeded by 15 minutes. To report a unit of 99417, 993X0, 15 minutes of time must have been attained. Do not report 99417, 993X0 for any time increment of less than 15 minutes.

When reporting 99417, 993X0, the initial time unit of 15 minutes should be added once the time in the primary E/M code has been surpassed by 15 minutes. For example, to report the initial unit of 99417 for a new patient encounter (99205), do not report 99417 until at least 15 minutes of time has been accumulated beyond 60 minutes (i.e., 75 minutes) on the date of the encounter. For an established patient encounter (99215), do not report 99417 until at least 15 minutes of time has been accumulated beyond 40 minutes (i.e., 55 minutes) on the date of the encounter.

Time spent performing separately reported services other than the primary E/M service and prolonged E/M service is not counted toward the primary E/M and prolonged services time. For prolonged services on a date other than the date of a face-to-face evaluation and management encounter with the patient and/or family/caregiver. For E/M services that require prolonged clinical staff time and may include face-to-face services by the physician or other qualified health care professional. Do not report 99417, 993X0 in conjunction with 99358, 99359, 99415, and 99416.

Note that we referred The American Medical Association (AMA) 2023 ‘CPT E/M Descriptors and Guidelines’ for a detailed explanation of prolonged E/M codes for 2023. Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle services. Our coding team is well versed with such revised billing guidelines and payer-specific policies which ensures accurate medical billing.

As your prime focus is patient care, you may not able to dedicate quality time to billing updates, resulting in delayed or denied payments. Our assistance in medical billing and coding will ensure, clean claim submission along with an opportunity of maximizing practice collections. Email us at: info@medicalbillersandcoders.com or call us at: 888-357-3226 to know how we can reduce your billing burden and increase practice collections.


Published By - Medical Billers and Coders
Published Date - Nov-25-2022 Back

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