Coding for prolonged services: CPT and HCPCS codes

Common rules:

• Prolonged services codes are add-on codes to E/M services.
• 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.

Where the rules vary:

• There are different CPT® and HCPCS codes that describe the same prolonged care services.
• Office services have time ranges. CPT® uses the lower time value in the range to calculate when prolonged care can be used. CMS uses the higher time value in the range to calculate when prolonged care can be used.
• 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 use the time in the CMS time file, 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.
• 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

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Coding prolonged services in the office

Office services
CPT 99417: 15 minutes		HCPCS G2212: 15 minutes
Add to	Notes	Add to	Notes
99205, 99215, 99245 codes: see below	CPT uses lowest value in time range, CMS uses highest value in time range. CPT allows with consults.	99205, 99215	CMS uses highest value in time range for CPT codes. CMS does not recognize consult codes.

Note: For home and residence services and assessment of cognitive functions, see below.

Coding for prolonged services is complicated by the fact CPT^® and CMS use different codes and different time thresholds. These codes and rules have been in effect since 2021.

• The AMA developed CPT^®code 99417 for 15 minutes of prolonged care, done on the same day as office/outpatient codes 99205 and 99215.
• Medicare has assigned a status indicator of invalid to code 99417, and developed a HCPCS code to replace it, G2212
• If using either code, only report it with codes 99205 and 99215, use only clinician time, and use it only when time is used to select the code
• Use for time spent face-to-face and in non-face-to-face activities

In their 2021 Physician Fee Schedule Final Rule, CMS indicated its agreement with the new E/M definitions for codes 99202-99215 that were developed by the AMA that are in the 2021 CPT^® book. However, CMS and the AMA are not in agreement about the use of prolonged care code 99417, resulting in HCPCS code. The disagreement stems from whether to start counting the 15 minutes of prolonged care at the minimum time threshold for the code or the maximum time threshold.

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Using time for E/M services

A practitioner may include these activities in their time, when using time to select an E/M service:

• preparing to see the patient (eg, review of tests)
• obtaining and/or reviewing separately obtained history
• performing a medically appropriate examination and/or evaluation
• counseling and educating the patient/family/caregiver
• ordering medications, tests, or procedures
• referring and communicating with other health care professionals (when not separately reported)
• documenting clinical information in the electronic or other health record
• independently interpreting results (not separately reported) and communicating results to the
  patient/family/caregiver
• care coordination (not separately reported)

Per CPT, use 99417 for office visits, outpatient consults, home and residence services and cognitive assessment planning.

# ✚  99417  Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)

(Use 99417 in conjunction with 99205, 99215, 99245, 99345, 99350, 99483)
(Do not report 99417 on the same date of service as 90833, 90836, 90938, 99358, 99359, 99415, 99416)
(Do not report 99417 for any time unit less than 15 minutes)

The new add-on prolonged services code may only with the codes listed above.

• You can’t report the new add on code on the same day as psychotherapy, non-face-to-face prolonged care codes 99358, 99359 or staff prolonged care codes.
• The time reported must be 15 minutes, not 7.5 minutes. The entire 15 minutes must be done, in order to add on this new, prolonged services code.

CMS developed its own code G2212

G2212 Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (List separately in addition to CPT^® codes 99205, 99215 for office or other outpatient evaluation and management services)

(Do not report G2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416).
(Do not report G2212 for any time unit less than 15 minutes)).”

Codes	Time range	CPT®: times to add on 99417	CMS: times to add on G2212
99205	60-74 min.	75-89 min.	89-103 min.
99215	40-54 min.	55-69 min.	69-83 min.

Cognitive assessment planning
CPT 99417		HCPCS code G2212
Add to	Notes	Add to	Notes
99483	Use CPT code times on the date of service only	99483	Use time three days before visit, date of visit and 7 days after visit

Both CMS and CPT allow a prolonged service in addition to 99483, assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home. The typical time for this code is 60, making the threshold time to add a prolonged care code 75 minutes. Note that CMS allows the practitioner to include time spent three days before the date of the visit and seven days after.

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Coding prolonged services in a home or residence

Home and residence services
CPT 99417		HCPCS code G0318: 15 minutes
Add to	Notes	Add to	Notes
99345, 99350	Use CPT code times on the date of service only	99345, 99350	Use time three days before visit, date of visit and 7 days after visit

For CPT®, use add-on code 99417 for prolonged care. As with all of these codes, both CPT®️ and HCPCS, the prolonged code may only be added to the highest-level code in the category and then only when time is used to select the service.  The definition of 99417 is above.

G0318 (Prolonged home or residence evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to CPT codes 99345, 99350 for home or residence evaluation and management services). (Do not report G0318 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99417). (Do not report G0318 for any time unit less than 15 minutes))

CMS is allowing time on days prior to and after the date of the encounter to be used for prolonged services in relation to home/residence visits.

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Coding prolonged services in the hospital: CPT and HCPCS codes

Inpatient and observation services
CPT 99418: 15 minutes		HCPCS code G0316: 15 minutes
Add to	Notes	Add to	Notes
99223, 99233, 99236, 99255	Use CPT code times on the date of service only	99223, 99233, 99236	99223, 99233 use time only on date of visit. For 99236, use time on date of visit to three days after. CMS does not recognize consult codes.

99418 Prolonged inpatient or observation evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time (List separately in addition to the code of the inpatient and observation Evaluation and Management service)

(Use in 99418 conjunction with 99223, 99233, 99236, 99255, 99306, 99310)
(Do not report 99418 on the same date of service as 90833, 90836, 90838, 99358, 99359)
(Do not report 99418 for any time unit less than 15 minutes)

99418 may be used on the highest-level initial and subsequent inpatient and observation codes, inpatient consult, and initial and subsequent nursing facility services. It may not be reported with psychotherapy or non-face to face prolonged care codes, or discharge services 99238, 99239, 99315, 99316. It may not be used with Emergency Department codes. The full 15 minutes is required and time must have been used to select the level of service.

As expected, CMS is not recognizing the new CPT^® code 99418. For Medicare patients, there is a HCPCS code. CMS is not using the published CPT typical times for the codes, but the time in the CMS time file, developed by the RUC. For Medicare patients, the time thresholds to add G0316 are different than those in our CPT books. CMS is not using allowing practices to report G0316 when the time is 15 more minutes than the CPT^® typical time. Instead, in a break from prior policy, CMS is using the time in the CMS time file. The 2023 time file is here.

G0316 Prolonged hospital inpatient or observation care evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to CPT^® codes 99223, 99233, and 99236 for hospital inpatient or observation care evaluation and management services). (Do not report G0316 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99418). (Do not report G0316 for any time unit less than 15 minutes)

See the CMS Table 24 below. CMS is allowing time on after the date of the encounter to be used for prolonged services in relation to hospital services.

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Coding prolonged services in a nursing facility

Prolonged services in a nursing facility: CPT code 99418/HCPCS code for Medicare G0317

Nursing facility care
CPT 99418: 15 minutes		HCPCS code G0317: 15 minutes
Add to	Notes	Add to	Notes
99306, 99310	Use CPT code times on the date of service only	99306, 99310	Use time one day before visit, date of visit and three days after visit

CPT^® defines the new prolonged add-on code 99418 (above) as the code to use in a nursing facility, as well as in the hospital. And, CPT®️ simply states to use the code when the total time of the highest-level service (selected based on time) is 15 minutes more than the time described in the CPT®️ book. Both the base time and the prolonged time can include face-to-face care and non-direct care on the date of the visit.

G0317 (Prolonged nursing facility evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to CPT codes 99306, 99310 for nursing facility evaluation and management services). (Do not report G0317 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99418,). (Do not report G0317 for any time unit less than 15 minutes))

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Table 24 Required Time Thresholds to Report Other E/M Prolonged Services

Primary E/M Service	Prolonged Code*	Time Threshold to Report Prolonged	Count physician/NPP time spent within this time period (surveyed timeframe)
Initial IP/Obs. Visit (99223)	G0316	90 minutes	Date of visit
Subsequent IP/Obs. Visit (99233)	G0316	65 minutes	Date of visit
IP/Obs. Same-Day Admission/Discharge (99236)	G0316	110 minutes	Date of visit to 3 days after
IP/Obs. Discharge Day Management (99238-9)	n/a	n/a	n/a
Emergency Department Visits	n/a	n/a	n/a
Initial NF Visit (99306)	G0317	95 minutes	1 day before visit + date of visit +3 days after
Subsequent NF Visit (99310)	G0317	85 minutes	1 day before visit + date of visit +3 days after
NF Discharge Day Management	n/a	n/a	n/a
Home/Residence Visit New Pt (99345)	G0318	140 minutes	3 days before visit + date of visit + 7 days after
Home/Residence Visit Estab. Pt (99350)	G0318	110 minutes	3 days before visit + date of visit + 7 days after
Cognitive Assessment and Care Planning (99483)	G2212	100 minutes	3 days before visit + date of visit + 7 days after
Consults	n/a	n/a	n/a

* Time must be used to select visit level. Prolonged service time can be reported when furnished on any date within the primary visit’s surveyed timeframe, and includes time with or without direct patient contact by the physician or NPP. Consistent with CPT’s approach, we do not assign a frequency limitation.

The source of this chart is CMS’s 2023 Final Rule. It doesn’t follow CPT typical times, or CPT prolonged services rules. It includes time for some services on the days before or after the face-to-face encounter.  It adds to confusion and complexity for medical practices.

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Implementation of using prolonged care HCPCS codes

It was never easy for clinicians to select prolonged services codes. When they were applicable to all levels of service, the threshold time was different for each code. Now, they are only applicable on the highest level of service, but there are two sets of codes and the time thresholds are different for each one. This makes no sense. Effectively, all prolonged services coding will need to be done by coders. Effectively, it is so byzantine that most practices will never be able to bill for them.

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Add-on prolonged services HCPCS codes

Question:

Can an add-on code to be submitted without its primary code? In particular, the add-on prolonged services HCPCS codes developed by CMS.

Answer:

An add-on code must be submitted with its primary code. A colleague said she was getting conflicting opinions about this. Let’s see what CPT® and CMS say.

Page xvi of the CPT® Professional Edition 2023 states, “Add-on codes are always performed in addition to the primary service or procedure and must never be reported as a standalone code.” It is easy to ignore the information in the introduction of the CPT® book but when I’m stuck, I regularly find answers there. And wish I had started looking there in the first place!

What about CMS? CMS has edits in place to ensure that an add-on code is only paid when reported with a correct primary code. Naturally, they have three levels of edits but you can read about this on the CMS website.

I think the question was prompted by the fact that for certain services provided by practitioners in a facility the add-on prolonged care codes includes time the days before or in the days after the face-to-face encounter. You can see the chart from the CMS final rule and read about it here.

I don’t know what edits individual MACs are setting up for these codes, but I recommend that you continue to submit all add-on codes on the claim with the primary code, following CPT® rules and CMS guidance.

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Non-face-to-face prolonged services codes 99358, 99359

The non-face-to-face prolonged care codes are still active, billable codes. But, they may not be reported on the same date of service as 99202-99215 per CPT®. And, Medicare has given them a status code of invalid, which means they won’t pay for it. And, there is not a replacement code for this service for Medicare.

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Implementing prolonged services codes

Question:

I understand from your article about prolonged services in 2021 that CMS won’t pay for prolonged code 99417 and instead developed a HCPCS code for the service. (G2212)   Do you have any recommendations about how to manage this in the office?

Answer:

Although in general, I believe most clinicians can code for most of the work they do (not a universally held opinion, I know) this is a case where the claims must go to a coder for review. Not only are there different codes depending on payer, the time thresholds are different. CPT® allows you to add the 15 minutes to the lower time threshold in the range, and CMS requires you to add the 15 minutes to the higher time threshold in the range.

Just a few reminders. The prolonged codes can only be used on 99205 and 99215, and only when time is used to select the office visit code. The total time must be documented. CMS’s manual does not currently require start and stop times. Look for a description of what activities are included in the time, because this is required when using time to select the office visit codes. “I spent 90 minutes caring for the patient today. It included reviewing test results, documenting in the record and arranging for follow up at pain management. It also included an extensive discussion with the patient and his sister about treatment options and recovery time, if he decides on surgery.”

Source documents

• EM from 2020 Final Rule
• G2212 from 2021 Final Rule

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