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.
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.
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.
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).
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.
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.
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