Coding for Prolonged Services: CPT and HCPCS Codes

Common rules:

• Prolonged services codes are add-on codes to the highest level E/M services in certain categories.
• In order to use prolonged care, the primary code must be selected based on time. This is in the CPT and HCPCS definition of prolonged services.
• Prolonged services codes may only be added to the highest-level code in the category.
• The full 15 minutes of prolonged services must be met. These do not follow the CPT mid-point time rule.
• The work of the prolonged care may include both face-to-face and non-face-to-face time.
• Prolonged care services can no longer be used on psychotherapy codes. There is no replacement code.
• For CPT codes, use prolonged code 99417 for office services, consults, home and residence services and cognitive assessment; For hospital and nursing facility codes, use 99418.
• CMS has three prolonged care codes. G2212 for office and cognitive assessment, G0318 for home and residence services and G0316 for inpatient and observation services.

Where the rules vary:

• There are different CPT® and HCPCS codes that describe the same prolonged care services.
• Time ranges were removed from the office visit codes in 2024, and now have only a single, threshold time listed. CMS didn’t change its manual or time thresholds for using prolonged care in response to this.
• For other services (hospital, nursing facility and home and residence services), CPT® uses the times stated in the CPT® book for the primary code when calculating if a prolonged services code may be added. CMS uses the time in the CMS time which includes pre and post visit times on other days, to calculate if prolonged care services may be added to hospital, nursing facility and home and residence services. These are in the Medicare Claims Processing Manual, Ch. 12 30.6.15
• CPT® includes only time spent on the date of the encounter. For hospital, nursing facility and home and residence services, CMS uses time on other dates of service.
• CPT® still has non-face-to-face prolonged care in the CPT® book, codes 99358, +99359 which can be used on days that do not include a face-to-face visit. CMS has given them a status indicator of invalid and doesn’t pay for them. There is no replacement of these services for Medicare patients.
• Home and residence services
• Hospital services
• Nursing facility for services
• Table 24 from the Final rule
• Implementing prolonged services codes