- The AMA has developed a new CPT code for 15 minutes of prolonged care, done on the same day as office/outpatient codes 99215 and 99205. The new code is 99417.
- There will be 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).
- These rules add to the changes for using time for office/outpatient codes in 2021.
- Don’t miss Betsy’s in-depth look at Prolonged Services in our September webinar
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
In their 2020 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 released in draft form in July, 2019.
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, and domiciliary care services. 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.
New prolonged care code 99417
CPT developed a prolonged care code, which we’ll see when the 2021 books are released, 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
Notice the editorial comments. This 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. It may not be used on the same date as non-face-to-face prolonged care codes 99358, 99359 or face-to-face prolonged care codes 99354, 99355. And, 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.
Codes 99202—99215 now have time ranges, rather than a single, threshold time.
|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|
For new patients, CPT says, “For services 75 minutes or longer, see Prolonged Services 99417” and for established patients, “For services 55 minutes or longer, see Prolonged Services 99417.” Keep in mind their instruction that a full additional 15 minutes must be met for prolonged care. Their chart (on page 16 of the cited document which you can download below), however, doesn’t make that entirely clear. Their words are clear, but the chart isn’t. See the warning below.
Warning: the CPT chart, below, and the CMS chart from their August 3, 2020 Proposed Rules don’t match! In the CPT Assistant, September 2020, it says “Furthermore, the calendar year (CY) 2021 physician fee schedule (PFS) proposed rule, released August 3, 2020, introduces alternative interpretations to time reporting for the new prolonged service(s) code. As stated above, users should consult the CPT 2021 code set and online updates for potential guideline adjustments.”
Unless and until CPT and CMS see eye to eye on this, and agree about the threshold time to bill 99417, groups will either have to use one set of time thresholds for Medicare patients and another for other payers, or use the more conservative Medicare time thresholds. This may not make much of a difference for most practices, because the required times are high, and many groups don’t schedule appointments of those lengths. But, some specialties and some clinicians do, and they will have to make a decision about this issue.
|Total Duration of new Patient or Other Office or Other Outpatient Services
(use with 99205)
|less than 75 minutes||Not reported separately|
|75-89 minutes||99205 X 1 and 99417 x 1|
|90-104 minutes||99205 X 1 and 99417 x 2|
|105 or more||99205 X 1 and 99417 x 3 or more for each additional 15 minutes.|
|Total Duration of Established Patient
Office or Other Outpatient Services
(use with 99215)
|less than 55 minutes||Not reported separately|
|55-69 minutes||99215 X 1 and 99417 x 1|
|70-84 minutes||99215 X 1 and 99417 x 2|
|85 or more||99215 X 1 and 99417 x 3 or
more for each additional 15 minutes.
CMS, in its 2021 Proposed Rule is making it crystal clear that in order to use prolonged care code 99417 with 99205 or 99215 a clinician must meet the highest time in the range plus 15 minutes. For 99205, the highest time in the range is 74 minutes. In order to report 99417 with 99205 the clinician must spend 89 (74+15) minutes in direct or non-direct patient care on that date of service. In order to report 99417 with 99215 the clinician must spend 69 (54+15) minutes in direct or non-direct patient care on that date of service.
TABLE 22: Proposed Prolonged Office/Outpatient E/M Visit Reporting – New Patient
|CPT Code(s)||Total Time Required for Reporting*|
|99205 x 1 and 99417 x 1||89-103 minutes|
|99205 x 1 and 99417 x 2||104-118 minutes|
|99205 x 1 and 99417 x 3 or more for each additional 15 minutes.||119 or more|
*Total time is the sum of all time, including prolonged time, spent by the reporting practitioner on the date of service of the visit
TABLE 23: Proposed Prolonged Office/Outpatient E/M Visit Reporting – Established Patient
|CPT Code(s)||Total Time Required for Reporting*|
|99215 x 1 and 99417 x 1||69-83 minutes|
|99215 x 1 and 99417 x 2||84- 98 minutes|
|99215 x 1 and 99417 x 3 or more for each additional 15 minutes.||99 or more|
*Total time is the sum of all time, including prolonged time, spent by the reporting practitioner on the date of service of the visit.
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.