Accurate Use of Prolonged Services CPT Code

Billing for Prolonged Services

Physicians have been billing prolonged services for a long time but in recent years the number of codes involved has grown and their requirements have changed, making them a potentially risky area for providers. In this article, we shared coding guidelines for the accurate use of prolonged services CPT code. Before we dive in, it’s worth noting that prolonged services have appeared more than once on the list of audit targets pursued by the HHS Office of Inspector General (OIG).

The necessity of prolonged services are considered to be rare and unusual, the agency has opined in one of its past targeting memos. Agency also mentioned that they will determine whether Medicare payments to physicians for prolonged E/M services were reasonable and made in accordance with Medicare requirements.

Coding Guidelines for Prolonged Services

• Most of the time, private insurance will separately reimburse physicians or other qualified healthcare professionals for Prolonged Services when reported in conjunction with companion Evaluation & Management (E/M) codes or other services.
• In accordance with The Centers for Medicare and Medicaid Services (CMS) and American Medical Association (AMA), Prolonged Services without Direct Patient Contact (CPT codes 99358-99359) will not be separately reimbursed when reported with Care Management (CM) CPT codes 99484, 99487, 99489, 99490, 99492-99494, G2058 and Transitional Care Management (TCM) CPT codes 99495 and 99496.
• Private insurance carriers reimburse Prolonged Services when reported with E/M codes in which time is a factor in determining the level of service in accordance with CPT and or HCPCS guidelines.
• Physicians or other qualified health care professionals should report only Prolonged Services beyond the typical duration of the service on a given date, even if the time spent by the physician or other qualified health care professional is not continuous.
• Providers should not include the time devoted to performing separately reportable services when determining the amount of prolonged services time. For example, the time devoted to performing cardiopulmonary resuscitation (CPT code 92950) should not be included in prolonged services time. Prolonged service of less than 30 minutes total duration on a given date is not separately reported because the work involved is included in the total work of the evaluation and management codes.
• According to CPT and HCPCS, prolonged service codes 99354-99357, 99359, 99415-99416, 99437, 99439, and G0513-G0514, G2212 are considered add-on codes and should not be reported without the appropriate primary code.
• Medicare has assigned a status indicator of invalid to code 99417 and developed an HCPCS code to replace it, G2212.
• Prolonged services for labor and delivery are not separately reimbursable services. As described in the American Congress of Obstetricians and Gynecologists (ACOG) coding guidelines, prolonged services are not reported for services that do not have a time component such as labor and delivery management.
• In accordance with CMS and the AMA, Prolonged Services without Direct Patient Contact (CPT codes 99358-99359) will not be separately reimbursed when reported with CM CPT codes 99417,99484, 99487, 99489, 99490, 99492- 99494, G2058, and TCM CPT codes 99495 and 99496.
• According to CPT, modifier 25 may be appended to prolonged services codes if there is adequate supporting documentation that describes the service provided and indicates the service is significant and separately identifiable from another service or procedure on the same date of service.

Prolonged Services CPT Code

+99417 and +G2212:

Add-on code +99417 relies on either 99215 or 99205 as the primary code. It becomes billable exactly one minute after the time threshold for 99215 or 99205 is exceeded. Thus to take 99205 as an example, one unit of +99417 is billable at 75 minutes. The 99205 accounts for the first 74 minutes. This is different from how +G2212 works; +G2212 is used by Medicare payers, though not exclusively. Some commercial payers are accepting +G2212 instead of +99417. This may be because +G2212 cannot be billed until 15 minutes past the time threshold for 99215 or 99205.

Again, taking 99205 as an example, +G2212 becomes billable only 15 minutes after the first 74 minutes covered by 99205 – starting at 89 minutes. Effectively, the use of +G2212 tacks 15 minutes of additional time onto 99215 and 99205 and saves payers that 15 minutes of prolonged service time. While both codes are billed at one unit per 15-minute time block, it’s important to verify applicable payer policies on which code to use. Remember that these prolonged services include non-face-to-face time spent before or after direct patient care if those times can be directly attributed to the patient encounter.

+99415 and +99416:

These two codes are used with office/outpatient E/M codes but are not limited to the level 5 codes only. These codes were revised in the year 2021 to clarify that they are no longer used with the older prolonged service codes 99354 and +99355. +99415 and +99416 describe prolonged service time spent by clinical staff during an E/M visit with direct patient contact. Rather than being reported as one unit per 15-minute block of time, +99415 is reported to cover up to the first 60 minutes of time after the ‘highest time in the range of total time’ of the E/M service, according to CPT guidelines. This follows the logic CPT uses for +99417. For each additional time block of up to 30 minutes, a unit of +99416 is supported. Remember that the CPT guidelines state the clinical staff should be spending time in direct patient contact under physician supervision.

99354 and +99355:

Prior to the year 2021, these codes were used in conjunction with office/outpatient E/M codes when prolonged time thresholds were met. After the year 2021, that function was transferred to the newly implemented add-on codes +99417 and +G2212 (as well as +99415 and +99416 for clinical staff time. This leaves +99354 and +99355 fairly limited usage options, such as outpatient consultation codes 99241-99245 for those commercial payers still reimbursing these codes, and then a variety of less frequently utilized outpatient codes. These include psychotherapy services (90837, 90847), domiciliary/rest home visits (99324-99337), home visits (99341-99350), and care planning services for cognitively impaired patients (99483).

99356 and +99357:

These codes are the inpatient/observation setting counterparts to 99354 and +99355. They were also revised in the year 2021 to account for the implementation of +99417 and +G2212, and the resulting changes to 99354 and +99355. 99356 and +99357 cover the total time spent by a physician or other provider at the patient’s bedside as well as on the patient’s floor or unit in the hospital or nursing facility, that exceeds the time threshold of the primary code (such as initial or subsequent hospital care). Please note that the time spent on the date of service does not have to be continuous.

99358 and +99359:

These two codes cover prolonged service time that does not involve direct patient contact, but was instead spent either before or after face-to-face patient contact. They were revised slightly to spell out that they are not to be used with 99202-99215. Remember that part of the 2021 CPT changes to codes 99202-99215 include new language stating that when these services are reported based on the provider’s time spent on the date of service, the time before and after direct patient contact can be included.

Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle services. We hope this article has given you a good understanding of the accurate use of prolonged services CPT code. To know more about our billing and coding services, contact us at: info@medicalbillersandcoders.com/ 888-357-3226.

CPT Copyright 2022: American Medical Association.

Reference: National Alliance of Medical Auditing Specialists

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Published By - Medical Billers and Coders
Published Date - Oct-18-2022 Back