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June 8, 2023

Prolonged services codes for Medicare preventive medicine services: G0513, G0514

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There are HCPCS prolonged services codes to be used with Medicare preventive services reported based on time.  CMS allows these prolonged care codes to be used with wellness visits.

Someone asked where to find the CMS chart with the intraservice guidelines. It is hidden deep on the CMS site! It is in the files that go with the 2018 Final Rule. Scroll down to about the 20th on the list and download 2018 List of Preventive Services Billed with Prolonged Preventive Codes.

Did you (or your clinician) ever have a wellness visit that took a really, truly, madly long time? And wondered what—if anything—you could bill with it? Wonder no more.

CMS has developed codes to be used with preventive medicine services that are time based.  These codes can be used in addition to the Welcome to Medicare visit, and initial and subsequent wellness visits.  These prolonged codes may also be used with other preventive services.  You can download a complete chart of codes using the link at the top of this page. I’ll discuss the other services later in the article.

Prolonged services and wellness visits

There are two new HCPCS codes that can be billed for wellness visits that are especially time consuming.

The provider must meet the threshold time for the visit, and half of the prolonged services time.

At an Open Door Forum, I asked if CMS was following the CPT® time rule for prolonged codes, and was told that they were.  The full time of the wellness visit must be met, however, before adding the time for the prolonged code.

HCPCS codes

G0513 Prolonged preventive service(s) (beyond the typical service of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first 30 minutes (listed separately in addition to code for preventive service)

G0514 Prolonged preventive service(s) (beyond the typical service of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (listed separately in addition to code for preventive service)

CPT® time rule

A unit of time is attained when the mid-point is passed. For example, an hour is attained when 31 minutes have elapsed (more than midway between zero and sixty minutes). A second hour is attained when a total of 91 minutes have elapsed.

https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html#PROLONGED

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Relevant Search Terms: add on codes for wellness visits, Prolonged care for wellness visits, new HCPCS codes

Last revised February 16, 2023 - Betsy Nicoletti
Tags: preventive services for medicare, primary care_preventive services

CPT®️️ is a registered trademark of the American Medical Association. Copyright American Medical Association. All rights reserved.

Audit tool for Modifier 25

Reasonable coders and practitioners can and do disagree about when a separate E/M service is warranted on the day of a minor procedure. This audit tool for modifier 25 will help determine if a separate E/M service should be reported. Using it consistently will help practices be reliable in their determinations and provide support in payer audits. Sign up for our monthly newsletter to download the reference sheet.

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Effective January 1, 2023, the AMA has revised the definitions and guidelines for hospital and other E/M services, including ED visits, nursing facility services, home services, and domiciliary care codes. Also, coding for prolonged care services gets another overhaul with revised codes and guidelines. Watch this webinar about all these changes.

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Our mission is to provide up-to-date, simplified, citation driven resources that empower our members to gain confidence and authority in their coding role.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions. For more about Betsy visit www.betsynicoletti.com.

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