- 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
- There are changes to the rules for use of existing codes 99354, 99355 (face-to-face prolonged care) and codes 99358, 99359 (non-face-to-face prolonged care)
Source documents at the end of this article: Pages from the 2020 Final Rule, pages from the 2021 Proposed Rule, CPT® draft changes for 2021, Pages from the calendar year 2021 Final Rule
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 and 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 a new HCPCS code.
Using time for office visit codes 99202 – 99215
In 2021, there will be two sets of time rules that govern E/M services, one set for office/outpatient codes 99202–99215, and one set for hospital, observation, ED, nursing facility, home, domiciliary care services and consultation codes. When selecting an office visit code, the clinician may use either the new medical decision making definitions, or total time spent on that date of service. You may include time spent by the billing practitioner doing these activities:
- 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
- care coordination (not separately reported)
Counseling and/or coordination of care will no longer need to dominate the service for these codes. Use the billing practitioner’s time only, not clinical or non-clinical staff time. The nature of the work must require practitioner knowledge and expertise. Waiting on hold for pre-cert authorization would not qualify; a peer-to-peer discussion with a physician at an insurance company would qualify.
Use only clinician time, not staff member time, when using time to select an office/outpatient code and the add-on prolonged care code.
New prolonged care code 99417
CPT® developed a prolonged care code, which is in the 2021 CPT®, for each additional 15 minutes of time spent on the calendar day of service. This prolonged services code is used to report total time, both with and without direct patient contact, after the time threshold for 99205 or 99215 is met. If time is spent performing other services identified by a CPT® code, do not include that time in the office visit or prolonged care service. The total time of 15 minutes must be met to report 99417, not the midpoint time.
# ✚ ● 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)
(Do not report 99417 in conjunction with 99354, 99355, 99358, 99359, 99415, 99416)
(Do not report 99417 for any time unit less than 15 minutes) Can’t get rid of the line space above
The new add-on prolonged services code may only be used with 99205 and 99215. It may not be used with any other office/outpatient code.
- You can’t report the new add on code on the same day as non-face-to-face prolonged care codes 99358, 99359 or face-to-face prolonged care codes 99354, 99355.
- 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 to 99215 and 99205.
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)).”
- CMS finalized in their calendar year 2021 rule that they do not agree with the CPT chart for using time for 99417.
- For Medicare patients, use the HCPCS code G2212. For other payers, it will be important to check their policies. CMS requires start and stop times for prolonged codes 99354, 99355 o it would be prudent to document start and stop times. The wRVUs for G2212 are .61, and national non-facility payment about $31.40 and about $30 for the national facility payment.
|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.|
Non-face-to-face prolonged care codes 99358, 99358
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. If non-face-to-face prolonged care is performed by the billing practitioner on the day of an office/outpatient visit, include that in the total time for the day. See the list of activities that may be included, at the start of this article.
Face-to-face prolonged care codes 99354, 99355
These are still active, billable codes, but they may not be reported with codes 99202–99215. They may be reported for prolonged care services with psychotherapy codes 90837, 90847, with office consultation codes 99241—99245, with domiciliary care codes 99324—99337, with home visit codes 99341—99350, and with cognitive assessment code 99483.
- CPT changes EM 2021
- EM from 2020 Final Rule
- Prolonged from 2021 Proposed Rule
- G2212 from 2021 Final Rule