Coding for prolonged services

Coding for prolonged services is not easy

CPT^® deleted prolonged services codes 99354, 99355, 99356, & 99357 in the 2023 CPT book
Non-face-to-face prolonged care codes 99358 and 99359 are still active codes, but Medicare won’t recognize them. They gave them a status indicator of Invalid for 2023
There are two prolonged services codes for office and other outpatient service, CPT^® code 99417 and HCPCS code G2212. CMS doesn’t recognize (or pay) 99417. Here’s the link to learn about 99417-and-G2212.
Similarly, there are two codes to use when coding for prolonged services for inpatient or observation visits, 99418 and G3016
According to CPT^®, you can also use 99418 in the nursing facility for prolonged care, but CMS requires G0317.
CPT^® does not have a prolonged care code for care in a patient’s home or in a residence such as assisted living, but there is a HCPCS code, G0318.
And, CPT^® and CMS again disagree on the threshold times required to report these 15-minute add-on codes. In a break from the past, CMS is using the times in the Medicare time file not the times in the CPT^® book for G0316, G0317 and G0318.
And, here’s the chart from CMS. Table 24 from the Final rule

Coding prolonged services in the hospital: CPT and HCPCS 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. And, as expected, the time thresholds are unique. Really unique. CMS is not using the published typical times for the codes, but the time in the CMS time file, developed by the RUC.

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)

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 2022 time file is here. The 2023 file will be posted soon. But, CMS has a chart in the Final Rule that shows the threshold times. (See Table 24 below)

And looking at that chart, CMS is allowing a practitioner to include time on the date of the visit, and for three days after the date of the visit. How a practice will track and manage that is beyond my understanding.

Notice that the CPT^® prolonged services codes can be used for nursing facility services and consultations, but the HCPCS code is for hospital only. CMS doesn’t recognize consults, and they developed a separate HCPCS codes to be used for coding for prolonged services in a nursing facility.

Coding prolonged services in a nursing facility

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

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.

CMS developed yet another prolonged code and is again using the time in the RUC time file. In my memory, this is a first and a completely new policy decision. You’ll need to look at TABLE 24 to see the times. Notice that CMS states you can use time spent the day before the visit, the day of the visit and for three days after the visit. Again, how this will be tracked, managed and documented is a nightmare.

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))

Coding prolonged services in a home or residence

CPT^® does not provide a prolonged services code for service performed in a home or residence. 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. They outdid themselves here. Include time spent by the practitioner three days before the visit, the day of the visit and for seven days after the visit.

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))

Implementation of using prolonged care 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.

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	105 minutes	Date of visit
Subsequent IP/Obs. Visit (99233)	G0316	80 minutes	Date of visit
IP/Obs. Same-Day Admission/Discharge (99236)	G0316	125 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.

Coding prolonged services in the office

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
Everyday Coding Q&A – Implementing prolonged services codes

Source documents at the end of this article: Pages from the 2020 Final 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 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 the new 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. Page down for the chart comparing the two.

Using time for office visit codes 99202 – 99215

There are 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 medical decision making, 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
patient/family/caregiver
care coordination (not separately reported)

Counseling and/or coordination of care will no longer need to dominate the service for codes 99202-99215. 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.

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)

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, so it would be prudent to document start and stop times.

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 services 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 services 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.

Time ranges for CPT® codes 99205-99215

Code	Time range	Code	Time range
99202	15-29 minutes	99212	10-19 minutes
99203	30-44 minutes	99213	20-29 minutes
99204	45-59 minutes	99214	30-39 minutes
99205	60-74 minutes	99215	40-54 minutes

Source documents

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.”

Calculating time for prolonged care

Question:

How is CMS calculating time for prolonged care?

Answer:

That’s the question on everyone’s mind. And, unless you’ve looked at the 3000 page Final Rule (or continue to read this post) you won’t find the answer. This question relates to prolonged care for hospital services, nursing facility services and home and residence services.

How it should work: A 15-minute unit of prolonged care time is added to the typical time to the highest level code in the category, when time is used to select the code. If the typical time is 35 minutes, then prolonged services is billed if the total time is 50 minutes. It can be time spent in direct care or in non-face-to-face activities. The typical time are in the CPT® book.

How it will work for Medicare: A 15-minute unit of prolonged care time will be added to the time in the CMS’s physician time file. What is this time file? It is a file that lists CPT® and HCPCS codes and time spent in pre-evaluation time, pre-positioning time, pre-service time, median service time, immediate post-service time and the number of post op visits included in a surgical procedure. There is a sum of those columns for the total time spent before, during and after the procedure, based on survey data. We typically look at this file when thinking about the value of surgical procedures.

But, it includes E/M services, as well. For example, in the 2022 file, 99221 has ten minutes of pre-evaluation time, 30 minutes of service time, and 10 minutes of post service time. The CPT® typical time in 2022 for 99221 is 30 minutes—the service time. (The typical times change in CPT® in 2023 for hospital services, but I’m using 2022 in this example.) Using CPT® rules, prolonged care could be added when 45 minutes was spent. Using Medicare rules, prolonged services could be reported when 65 minutes was spent: 10 minutes pre, service time, 30 minutes service time, 10 minutes post service time + 15 minutes.

It is a complete change in policy. And one that will cause confusion and errors. Their policy manual isn’t updated yet—this was published in their rule on November 1^st, and it takes time for the manual revisions to be done.

To make matters worse, some of the prolonged services codes can include time before the visit date and after.

Here’s their chart. I apologize if this is hard to understand. I’ve taken the 60 pages in the rule related to prolonged care and explained it in as few words as I could.

Betsy

Get more tips and coding insights from coding expert Betsy Nicoletti.