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March 1, 2024

Coding for prolonged services: CPT and HCPCS codes

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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.
  • In the 2024 CPT book, time ranges were removed from the office visit codes, and they now have only a single, threshold time listed. CMS has changed its manual or time thresholds for using prolonged care in response to this.
  • 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 uses 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

Coding prolonged services in the office.

CMS does not recognize consultation 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 99415, 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.

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)

(Use 99417 in conjunction with 99483, when the total time on the date of the encounter exceeds the typical time of 99483 by 15 minutes or more.)

  • You can’t report the new add on code on the same day as 90833, 90936, 90838, 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)).”

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.

Coding prolonged services in a home or residence

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.

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. 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.

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.

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) )

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

* 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.

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.

Add-on prolonged services HCPCS codes

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

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 xviii of the CPT® Professional Edition 2024  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.

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.

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?

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

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

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Last revised December 18, 2023 - Betsy Nicoletti Tags: CPT updates , prolonged care

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New prolonged service CPT code for 2021

Billing, Coding & Payments | September 21, 2020

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Beginning in 2021, there will be a new code for reporting prolonged services together with an office visit. The new code, CPT Code 99417, replaces CPT Codes 99354 and 99355. It can be used to report the total prolonged time with and without direct patient contact on the same day as an office visit. However, certain conditions apply:

  • It can only be reported in conjunction with the level 5 visit codes (CPT 99205, 99215).
  • The time must exceed the minimum time for primary E&M service.
  • Time alone must be the basis for coding.

For example, the range of time listed for 99205 is 60-74 minutes. The prolonged service code (99417) can be reported with 99205 when the total physician time exceeds the minimum time (60 minutes) for 99205 by at least 15 minutes. Thus, physician time, with and without patient contact, would need to be at least 75 minutes to report a prolonged service code. For an established patient visit, 99417 could be reported with 99215, when total time is at least 55 minutes. The code can be reported for each incremental 15-minute period.

CMS is proposing reimbursement of approximately $32 for this service.

Unsure about billing E&M codes based on time? Review our previous Insider article about the  E/M changes taking effect in 2021 , including the ability to choose codes based solely on time.

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Be sure to stay up to date on coding and legislative changes.

During the College’s Annual Meeting, the Advocacy Council is hosting several opportunities to learn about the new codes for 2021 and any legislation that may impact your practice. These sessions will be presented by the College’s leading experts: Warner Carr, MD, FACAAI; Gary N. Gross, MD, FACAAI; James Sublett, MD, FACAAI; James Tracy, DO, FACAAI; and the College’s Washington consultant, Bill Finerfrock of Capitol Associates.

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Specific criteria must be met to use prolonged services codes :

While certain encounters may seem prolonged, CPT codes for prolonged services in inpatient and outpatient (e.g., office) settings can be reported only when specific criteria are met. This article will focus on how to code for prolonged services provided by physicians and other qualified health care professionals (OQHCP) in the office setting.

+ Designated add-on code, requires an appropriate primary code

There are two types of outpatient-based prolonged services:

  • Direct (face-to-face) +99354 and +99355
  • Non-direct (non-face-to-face) 99358 and +99359

For prolonged direct services:

  • A minimum of 30 minutes above the time listed in the primary code is required (see table for time increments).
  • Designated add-on codes can be reported only with the following primary service codes: 90837, 90847, 99201-99215, 99241-99245, 99324-99337, 99341-99350, 99483.
  • All designated primary codes are time-based.
  • Time spent by physician or OQHCP does not have to be continuous.
  • Only face-to-face time with patient and/or family (including guardians) is counted.
  • If reporting the primary service code based on time in lieu of key components, the time criteria in the highest code in the code set (e.g., 99215) must be met before prolonged service time can begin.
  • Code 99355 must be reported with 99354.

For prolonged non-direct services:

  • At least 30 minutes must be spent on a single calendar date (see table for time increments).
  • Prolonged services include time spent performing non-direct services such as chart reviews.
  • Prolonged services must relate to an upcoming encounter or a recent one.
  • Codes may be reported alone (99358) or in conjunction with another service.
  • Code 99359 must be reported with 99358.

cpt extended visit

Coding vignettes

An established patient and her mom present for an appointment to discuss management of the patient’s newly diagnosed type 1 diabetes. The visit lasts 75 minutes, of which over 50 minutes were spent on counseling and coordination of care.

Report CPT codes 99215 and 99354.

Coding tip: Because over 50% of the total face-to-face time was spent in counseling and coordination of care, time is the controlling factor. That means the time in the highest code in the code set must be met prior to starting prolonged time. The typical time for code 99215 is 40 minutes, which leaves 35 minutes of prolonged service time. Code 99354 is reported for 30-74 minutes of prolonged time.

In the morning, a physician sees a new adolescent patient for anxiety issues. The patient is still quite anxious after the appointment, so the physician tells the mom to return that day if needed. Later that day, the patient returns to discuss issues further and is referred to a specialist.

The physician spent 45 minutes with the mom and son in the morning, 35 minutes of which was spent in counseling. Later that day, the physician spent an additional 45 minutes in counseling/coordination of care.

Report CPT codes 99205 and 99354.

Coding tip: Because over 50% of the total face-to-face time was spent in counseling and coordination of care, time is the controlling factor in both encounters. Since the encounters are related and time spent does not have to be continuous, time from both encounters are added together. Remember that the time in the highest code in the code set must be met first prior to starting prolonged time. The typical time for a 99205 is 60 minutes, which leaves 30 minutes of prolonged service time. Code 99354 is reported for 30-74 minutes of prolonged time.

A developmental and behavioral pediatrician is scheduled to see a patient for the first time next week. Records from his school and primary care pediatrician are sent to assist in the initial exam. On the Friday before the appointment, the developmental and behavioral pediatrician spends roughly 45 minutes reviewing the records and writing a summary.

Report CPT code 99358.

Coding tip: Because the pediatrician performed more than 30 minutes of work on a single calendar date, non-direct prolonged services can be reported. Since 99358 is a stand-alone code, it can be reported on Friday before the initial encounter on Monday.

A developmental and behavioral pediatrician is scheduled to see a patient for the first time today. Records from his school and primary care pediatrician are sent to assist in the initial exam. In the morning prior to the appointment, the developmental and behavioral pediatrician spends roughly 20 minutes reviewing the records and writing a summary. The mom and patient then present to the office. The service will be reported based on key components (99204). A developmental test (96111) also is reported. The physician then spends 25 minutes after the encounter reviewing information the mom brought in from a previous developmental and behavioral pediatrician.

Report CPT codes 99204 (with modifier 25), 99358 (with modifier 25) and 96111.

Coding tip: The encounter is being reported based on key components, which was 99204. In addition, 96111 is reported for the developmental testing. The non-direct service can be reported with 99358 because the total time for that calendar date (20 minutes plus 25 minutes later in the day) is greater than 30 minutes. Remember that time spent does not have to be continuous if it is on the same calendar date.

Becky Dolan contributed to this article. For coding and billing questions, email [email protected] .

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Follow these four steps to code quickly and accurately, while reducing the need to count up data points.

KEITH W. MILLETTE, MD, FAAFP, RPh

Fam Pract Manag. 2021;28(4):21-26

Author disclosure: no relevant financial affiliations.

cpt extended visit

The new rules for coding evaluation and management (E/M) office visits are a big improvement but still a lot to digest. 1 , 2 To ease the transition, previous FPM articles have laid out the new American Medical Association/CPT medical decision making guide 3 and introduced doctor–friendly coding templates (see “ Countdown to the E/M Coding Changes ,” FPM , September/October 2020), explained how to quickly identify level 4 office visits (see “ Coding Level 4 Visits Using the New E/M Guidelines ,” FPM , January/February 2021), and applied the new guidelines to common visit types (see “ The 2021 Office Visit Coding Changes: Putting the Pieces Together ,” FPM , November/December 2020).

After several months of using the new coding rules, it has become clear that the most difficult chore of coding office visits now is assessing data to determine the level of medical decision making (MDM). Analyzing each note for data points can be time-consuming and sometimes confusing.

That being the case, it's important to understand when you can avoid using data for coding, and when you can't. I've developed a four-step process for this (see “ A step-by-step timesaver ”).

The goal of this article is to clarify the new coding rules and terminology and to explain this step-by-step approach to help clinicians code office visits more quickly, confidently, and correctly.

The new evaluation and management office visit coding rules have simplified many things but are still a lot to digest, especially when it comes to counting data.

There are different levels of data and different categories within each level, which can make using data to calculate the visit level time-consuming and confusing.

By calculating total time, and then moving on to assessing problems and prescription drug management, most visits can be optimally coded without dealing with data at all.

OFFICE VISIT CODING RULES AND TERMINOLOGY

To make full use of the step-by-step process, we have to first understand the new rules, as well as coding terminology. Here is a brief summary.

Medically appropriate . Physicians and other qualified health care professionals may now solely use either total time or MDM to determine the level of service of an office visit. That means the “history” and “physical exam” components are no longer needed for code selection, which simplifies things. But your patient note must still contain a “medically appropriate” history and physical. So continue to document what is needed for good medical care.

New patient . A new patient is a patient who has not been seen by you or one of your partners in the same medical specialty and the same group practice within the past three years.

Total time and prolonged services . Total time includes all the time you spend on a visit on the day of the encounter (before midnight). It includes your time before the visit reviewing the chart, your face-to-face time with the patient, and the time you spend after the visit finishing documentation, ordering or reviewing studies, refilling medications, making phone calls related to the visit, etc. It does not include your time spent performing separately billed services such as wellness visits or procedures. Total time visit level thresholds differ for new patients vs. established patients. (See the total times in “ The Rosetta Stone four-step template for coding office visits .”)

The prolonged services code comes into play when total time exceeds the limits set for level 5 visits by at least 15 minutes.

Medical decision making . MDM is made up of three components: problems, data, and risk. Each component has different levels, which correspond to levels of service (low/limited = level 3, moderate = level 4, and high/extensive = level 5). The highest level reached by at least two out of the three components determines the correct code for the level of service. MDM criteria is the same for new and established patients.

Problems addressed . This includes only the problems you address at that specific patient visit. It does not include all the patient's diagnoses and does not include problems that are exclusively managed by another clinician. Problems addressed are separated into low-complexity problems (level 3), moderate-complexity problems (level 4), and high-complexity problems (level 5). To code correctly, you need to know the coding value of the problems you address. It is helpful to think of problems in terms of levels of service (e.g., a sinus infection is usually a level 3 problem, and pneumonia or uncontrolled diabetes are usually level 4 problems).

The simplest way to summarize problems is this: Life-threatening problems are level 5; acute or chronic illnesses or injuries are level 3 or 4 depending on how many there are, how stable they are, and how complex they are; and if there's just one minor problem, it's level 2.

(For more specifics see “ What level of problem did I address? ”)

Risk . Risk is also separated into “low” (level 3), “moderate” (level 4), and “high” (level 5) categories.

Level 3 risk includes the use of over-the-counter (OTC) medications.

Level 4 risk includes the following:

Prescription drug management: starting, stopping, modifying, refilling, or deciding to continue a prescription medication (and documenting your thought process),

Social determinants of health that limit diagnosis or treatment (this is when patients' lack of finances, insurance, food, housing, etc., affects your ability to diagnose, manage, and care for them as you normally would).

Level 5 risk includes the following:

Decisions about hospitalization,

Decisions about emergency major surgery,

Drug therapy that requires intensive toxicity monitoring,

Decisions to not resuscitate or to de-escalate care because of poor prognosis.

Data analyzed . For purposes of MDM, data is characterized as “limited” (level 3 data), “moderate” (level 4 data), or “extensive” (level 5 data). But each level of data is further split into Categories 1, 2, and 3. This can make calculating data complicated, confusing, and time-consuming. Here are the data components and terms you need to know.

Category 1 data includes the following:

The ordering or reviewing of each unique test , i.e., a single lab test, panel, X-ray, electrocardiogram (ECG), or other study.

Ordering and reviewing the same lab test or study is worth one point, not two; a lab panel (e.g., complete blood count or comprehensive metabolic panel) is worth one point,

Reviewing a pertinent test or study done in the past at your own facility or another facility,

Reviewing prior external notes from each unique source, including records from a clinician in a different specialty or from a different group practice or facility as well as each separate health organization (e.g., reviewing three notes from the Mayo Clinic is worth one point, not three, but reviewing one note from Mayo and one from Johns Hopkins is worth a total of two points),

Using an independent historian, which means obtaining a history from someone other than the patient, such as a parent, spouse, or group home staff member. (This is included in Category 2 for level 3 data, but falls into Category 1 for level 4 and 5 data.)

Category 2 data includes the following:

Using an independent historian (for level 3 data only),

Independent interpretation of tests, which is your evaluation or reading of an X-ray, ECG, or other study (e.g., “I personally reviewed the X-ray and it shows …”) and can include your personal evaluation of a pertinent study done in the past at your or another facility. It does not include reviewing another clinician's written report only, and it does not include studies for which you are also billing separately for your reading.

Category 3 data includes the following:

Discussion of patient management or test interpretation with an external physician, other qualified health care professional, or appropriate source. An external physician or other qualified health care professional is someone who is not in your same group practice or specialty. Other appropriate sources could include, for example, consulting a patient's teacher about the patient's attention deficit hyperactivity disorder.

A STEP-BY-STEP TIMESAVER

The majority of office visits can be optimally coded by using time or by looking at what level of problems were addressed (see Steps 1 and 2 below) and whether a prescription medication was involved.

A level 3 problem can be coded as a level 3 visit if you address it with an OTC or prescription medication. A level 4 problem can be coded as a level 4 visit if you order prescription medication or perform any other type of prescription drug management (modifying, stopping, or deciding to continue a medication). Most level 2 and level 5 office visits are straightforward, and most level 5 visits will be coded by time. They will typically be visits in which you address multiple problems or complicated problems and the total time exceeds 40 minutes for established patients. This is much more common than seeing critically ill patients who may require admission, which is another level 5 scenario. The few remaining patient visits that have not already been coded require analyzing data (Steps 3 and 4). (See “ The Rosetta Stone four-step template for coding office visits .”)

Step 1: Total time . Think time first. If your total time spent on a visit appropriately credits you for level 3, 4, or 5 work, then document that time, code the visit, and be done with it. But if it does not, go to Step 2.

Step 2: “Problems plus.” Don't be afraid to move on from time-based coding if you believe you performed a higher level visit using MDM. Many visits can be coded with MDM just by answering these two questions: What was the highest-level problem you addressed during the office visit? And did you order, stop, modify, or decide to continue a prescription medication?

If you addressed a level 2 problem and your total time was less than 20 minutes (or less than 30 for a new patient), then code level 2.

If you addressed a level 3 problem, plus you recommended an OTC medication or performed prescription drug management, then code level 3.

If you addressed a level 4 problem, plus you performed prescription drug management, then code level 4.

Chronic disease management often qualifies as level 4 work. For documentation, think “P-S-R”: problem addressed, status of the problem (stable vs. unstable), and prescription drug management (Rx). This trio should make it clear to coders, insurance companies, and auditors that level 4 work was performed.

For instance, if a patient has controlled hypertension and diabetes and you document that you decided to continue the current doses of losartan and metformin, that's level 4 (two stable chronic illnesses plus prescription drug management). If you see a patient with even one unstable chronic illness and document prescription drug management to address it, that's also level 4.

For a level 5 problem, if you see a really sick patient and decide to admit or consider admission (and you document your thought process in your note), then code level 5.

By starting with total time and, if necessary, moving on to “problems plus,” you will probably be able to optimally code 90% of your office E/M visits. But on the rare occasions when you see a patient for level 4 or 5 problems for less than the required time and don't do any prescription drug management, you may have to proceed to Steps 3 and 4.

Step 3: Level 4 problem with simple data or social determinants of health concerns . Code level 4 if you saw a patient for a level 4 problem and did any of the following:

Personally interpret a study (e.g., X-ray),

Discuss management or a test with an external physician,

Modify your workup or treatment because of social determinants of health.

Step 4: Level 4 or 5 problem with complex data . If you saw a patient for a level 4 problem and still haven't been able to code the visit at this point, you have to tally Category 1 data points:

Review/order of each unique test equals one point each,

Review of external notes from each unique source equals one point each,

Use of an independent historian equals one point.

Once you reach three points, code it as level 4.

For a level 5 problem, if you see a really sick patient, order/interpret an X-ray or ECG, and review/order two lab tests, then code level 5.

Following these steps should allow you to quickly identify the optimal level to code most any E/M office visit (for pre-op visits, see “ Coding pre-ops template .”)

Here's a catchy rhyme to remember the basic outline of the steps:

To finish fast ,

code by time and problems first ,

and save data for last .

By mastering the new coding rules and terminology and applying this four-step approach, you can code office visits more quickly, accurately, and confidently — and then spend more time with your patients and less time at the computer.

CPT Evaluation and Management (E/M) Office or Other Outpatient and Prolonged Services Code and Guideline Changes . American Medical Association. Accessed June 10, 2021. https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

E/M Office Visit Compendium 2021. American Medical Association; 2020.

Table 2 – CPT E/M office revisions level of medical decision making. American Medical Association. Accessed June 10, 2021. https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

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What are the Changes to Prolonged Services Coding in 2023?

by Loralee Kapp | Last updated May 16, 2023 | Published on Feb 24, 2023 | Medical Billing , Medical Coding

Coding for Prolonged Services

Physicians need to document their visits correctly and understand when their service can and cannot be reported using a prolonged services add on code.

With new codes and coding conventions for prolonged services in 2023, physicians can benefit immensely from outsourced medical coding services . Leading medical coding service providers are knowledgeable about revised codes and code selection facts, and can help physician practices report their services correctly and ensure proper payment.

cpt extended visit

Since joining our RCM Division in October 2021, Loralee, who is HIT Certified (Health Information Technology/Health Information Management), brings her extensive expertise in medical coding and Health Information Management practices to OSI.

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Understanding the long list of prolonged services in 2022 and beyond

cpt extended visit

April 22, 2022 | By Grant Huang , CPMA, CPC

Prolonged services have been around for a long time – no pun intended – but in recent years the number of codes involved has grown and their requirements have changed, making them a potentially risky area for providers. For this reason, auditors should take the time to brush up on the types of prolonged services there are to choose from. In this tip, we will do just that.

Before we dive in, it’s worth nothing that prolonged services have appeared more than once on the list of audit targets pursued by the HHS Office of Inspector General (OIG). “The necessity of prolonged services are considered to be rare and unusual,” the agency has opined in one of its past targeting memos . “We will determine whether Medicare payments to physicians for prolonged E/M services were reasonable and made in accordance with Medicare requirements.”

The OIG was referring specifically to the add-on codes associated with office/outpatient E/M codes 99202-99215, but in 2022 and beyond we have to contend with significant changes to some existing prolonged services codes as well as new add-on codes to be used with 99202-99215. Please refer to the table below for a complete list.

Breaking down the prolonged services codes:

  • +99417 and +G2212. These are the two codes likely to come up most frequently on audits for prolonged E/M services. Add-on code +99417 was created by CPT and relies on either 99215 or 99205 as the primary code. It becomes billable exactly one minute after the time threshold for 99215 or 99205 is exceeded – thus to take 99205 as an example, one unit of +99417 is billable at 75 minutes. The 99205 accounts for the first 74 minutes. This is different from how +G2212 works; +G2212 was established by CMS and is used by Medicare payers, though not exclusively. Some commercial payers are accepting +G2212 instead of +99417. This may be because +G2212 cannot be billed until 15 minutes past the time threshold for 99215 or 99205. Again, taking 99205 as an example, +G2212 becomes billable only 15 minutes after the first 74 minutes covered by 99205 – starting at 89 minutes. Effectively, the use of +G2212 tacks 15 minutes of additional time onto 99215 and 99205 and saves payers that 15 minutes of prolonged service time. While both codes are billed at one unit per 15-minute time block, it’s important to verify payer policies on which code to use. Remember that these prolonged services include non-face-to-face time spent before or after the direct patient care if those times can be directly attributed to the patient encounter. This is one reason why I expect the OIG to be taking a close look at utilization of these two codes going forward, when providers can count such activities as “time spent documenting in the EHR” after the patient is gone, towards the E/M service’s total time.
  • +99415 and +99416. Introduced in 2016, these codes are used with office/outpatient E/M codes but are not limited to the level 5 codes only. There were revised in 2021 to clarify that they are no longer used with the older prolonged service codes 99354 and +99355. +99415 and +99416 describe prolonged service time spent by clinical staff during an E/M visit with direct patient contact. Rather than being reported as one unit per 15-minute block of time, +99415 is reported to cover up to the first 60 minutes of time after the “highest time in the range of total time” of the E/M service, according to CPT guidelines. This follows the logic CPT uses for +99417. For each additional time block of up to 30 minutes, a unit of +99416 is supported. Remember that the CPT guidelines state the clinical staff should be spending the time in direct patient contact under physician supervision.
  • 99354 and +99355. Prior to 2021, these codes were used in conjunction with office/outpatient E/M codes when prolonged time thresholds were met. After 2021, that function was transferred to the newly implemented add-on codes +99417 and +G2212 (as well as +99415 and +99416 for clinical staff time. This leaves +99354 and +99355 fairly limited usage options, such as outpatient consultation codes 99241-99245 for those commercial payers still reimbursing these codes, and then a variety of less frequently utilized outpatient codes. These include psychotherapy services (90837, 90847), domiciliary/rest home visits (99324-99337), home visits (99341-99350), and care planning services for cognitively impaired patients (99483).
  • 99356 and +99357. These codes are the inpatient/observation setting counterparts to 99354 and +99355. They were revised in 2021 to account for the implementation of +99417 and +G2212, and the resulting changes to 99354 and +99355. 99356 and +99357 cover the total time spent by a physician or other provider at the patient’s bedside as well as on the patient’s floor or unit in the hospital or nursing facility, that exceeds the time threshold of the primary code (such as initial or subsequent hospital care). Note that the time spent on the date of service does not have to be continuous.
  • 99358 and +99359. These codes cover prolonged service time that does not involve direct patient contact, but was instead spent either before or after face-to-face patient contact. They were revised slightly to spell out that they are not to be used with 99202-99215. Remember that part of the 2021 CPT changes to codes 99202-99215 include new language stating that when these services are reported based on the provider’s time spent on the date of service, time before and after direct patient contact can be included.

Prolonged services have been an audit target for years, and Medicare and commercial payers have struggled to balance the need to reimburse encounters that take much longer than usual with the need to prevent fraud and abuse. Given the recent changes in 2021 to the office/outpatient E/M codes and their accompanying prolonged service codes, it’s a sure bet that payers will be scrutinizing utilization for any increases and conducting audits to ensure compliance with guidelines. Physicians looking to ensure that they are being properly reimbursed often ask me about prolonged services in case they are leaving “money on the table,” and it’s more important than ever to make sure that auditors have the answers ready.

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Find-A-Code Articles, Published 2023, January 31

Three things to know when reporting prolonged services in 2023.

by   Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT Jan 31st, 2023

Click HERE to register for this FREE webinar The 2023 Evaluation and Management (E/M) changes are significant and impactful and to ensure organizations have a solid knowledge of how to report these services correctly, we will focus on three key points that should be understood: 

CPT and Medicare report prolonged services using different codes

Cpt calculates time differently than medicare.

  • Other payers will follow Medicare guidelines 

In 2021, Medicare disagreed with the CPT guidelines specific to the times when prolonged services should begin being reported and now, in the 2023 E/M changes, Medicare once again disagrees as well. Here are three things you should know before reporting prolonged service codes 99417 and 99418 :

CPT has provided two new codes for reporting prolonged services:

99417 (added in 2021) is used to report prolonged services for the following codes: 99205 , 99215 , 99245 , 99345 , 99350 , and 99483 ; all services performed in the office or outpatient setting. Because Medicare disagrees with the CPT guidelines for reporting prolonged services, they have published G2212 for reporting outpatient prolonged services with those same primary CPT codes.

In 2023, CPT published code 99418 for reporting prolonged services in the inpatient or observation setting with primary codes 99223 , 99233 , 99236 , 99255 , 99306 , and 99310 . Because Medicare disagrees with the CPT guidelines for when prolonged codes may begin being calculated, it has developed three codes to replace 99418 , as well as a different set of guidelines:

  • G0316 Inpatient and Observation Care prolonged services
  • G0317 Nursing Facility prolonged services
  • G0318 Home and Residence prolonged services 

With the deletion of approximately 25 E/M codes, the RVS Update Committee (RUC) began resurveying the remaining E/M codes and provided recommendations to CMS, which included preservice, intra-service, and post-service times. These RUC recommendations and times were used by CMS to develop the guidelines for reporting prolonged services, creating a need for different codes and different guidelines than CPT had published.

CPT assigned specific time ranges to codes 99202 - 99215 and single times to Other E/M services. For codes 99205 and 99215 , the highest level in their respective E/M categories, there is a minimum and maximum time 99215 (40-54 minutes). When calculating time to report prolonged services code 99417 , CPT guidelines indicate to begin with the minimum time in the time range, add 15 minutes, and report the initial unit of 99417 at 55 minutes. Medicare, on the other hand, requires the maximum time in the time range to be met, exceeded by 15 minutes, and then counting of the 15 minutes of prolonged time may begin.

Total Provider Time: 78 minutes

Scoring: 

  • CPT guidelines allows one unit of 99417 at 55 minutes, beginning the prolonged service time clock at the minimum time in the time range (40 minutes). This means at 55 minutes the first unit of 99417 is reported and at 70 minutes, the second unit of 99417 is reported. Final Codes: 99215 , 99417 x 2 units.
  • Medicare guidelines allow one unit of G2212 at 70 minutes, beginning the prolonged service time clock at the maximum time in the time range (54 minutes). This means that at 54 minutes another 15 minutes must be exceeded before the initial unit of G2212 can begin to be counted. That time between 54-69 minutes does not garner a unit of G2212 but rather the initial unit is allowed at 70 minutes completed.

Other Payers May Follow Medicare Guidelines

Although Medicare develops policies specific to claims for services provided to Medicare beneficiaries, many commercial payers adopt them and make them policies of their own. This means whenever scoring prolonged services for a patient it is important to know which payers have published policies stating they will be following Medicare guidelines for coding prolonged services using G2212 , G0316 , G0317 , and G0318 . Because there is such an enormous difference between the two sets of guidelines, it could be helpful to maintain these guidelines in a location where they are easily accessible.

Join us for an upcoming webinar where we review the prolonged services guidelines for both CPT and Medicare, including examples of each.  That webinar, "The differences between Medicare and CPT, Reporting Polonged Services" is scheduled for Thursday, Feruary 2, 2023 @ 10:15 AM PT, 11:15 AM MT, 12:15 PM CT, 1:15 PM ET.

Click HERE to register for this FREE webinar .

About Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Image of Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Three Things To Know When Reporting Prolonged Services in 2023. (2023, January 31). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/three-things-know-reporting-prolonged-services-2023-37317.html

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A mental health billing service, extended sessions billing guide for mental health providers [2024].

PLEASE NOTE:  As of 2023, these codes have been removed by CMS and the AMA.  

Learning how to bill extended therapy sessions for mental health insurance claims can be a paid but our extended sessions billing guide will help cut down your learning curve.

If you’d rather leave it up to the professionals, consider hiring out your insurance billing to a service like TheraThink .  Otherwise grit your teeth and read on.

You’ll learn how to bill extended sessions for psychotherapy (90837), couples and family therapy (90847), and your diagnostic evaluations (90791).

extended sessions billing guide

We’ll also show you the 2020 Medicare extended session reimbursement rates for these add-on CPT codes.

  • Individual Therapy Over 60 Minutes
  • Reimbursement Rates
  • Couples Therapy Extended Time Guide
  • Video Guide

Billing Extended Sessions for Individual Therapy

It’s important to note that if you are seeing a client for 60 minutes or under, make sure to bill using CPT codes 90832, 90834, or 90837 alone.

Do not bill using add-on codes if sessions are not extended.

Learn more about billing CPT Code 90837 for individual therapy sessions or review our quick guide on how to bill 90 minute therapy sessions .

Extended Sessions Billing Guide for Couples and Family Therapy

Review our extensive billing guide on CPT Code 90847 for couples and family therapy billing for more information or consider hiring out this painful drudgery.

Extended Sessions for a Diagnostic Evaluation & E/M Codes

To ensure you can bill these extended session add-on codes, make sure you’re licensed and eligible to provide evaluation and management services as per your insurance panel contract.

The first two codes (CPT codes 90833 or 90836) describe conducting therapy after providing evaluation and management services, in this example in conjunction with a diagnostic evaluation (90791).

The second two codes, CPT Codes 99415 and 99416, are used to describe extended sessions for evaluation and management (E/M).

If you are billing with CPT Code 99416, you must use CPT Code 99415.

( Source ) ( Source )

Video Guide!

cpt extended visit

Extended Sessions Reimbursement Rates

You can conduct an eligibility and benefits verification call to your client’s insurance company and ask specifically about coverage for those CPT codes used in conjunction with the primary code (90837 or 90847 or 90791).

At TheraThink, we do this as part of our mental health insurance billing service for free (because, as you can tell, it’s a best practice).

There is no guarantee that these extended session CPT codes will be covered.  It’s best to call and ask for each client and obtain a reference ID as proof of that quote if problems come up in billing.

When using mental health add-on codes for services rendered after business hours or during evening, weekend, or holiday hours, call ahead to find out how your client’s insurance policy will approve the use of these procedure codes.

extended sessions reimbursement rates

CPT Add-On Code +99354 Reimbursement Rate (2022):  $ 140.26

— Additional time up to 1 hour and 45 minutes for a diagnostic interview

CPT Add-On Code +99354 Reimbursement Rate (2020):  $132.09

CPT Add-On Code +99354 Reimbursement Rate (2021):  $129.10

CPT Add-On Code +99355 Reimbursement Rate (2022):  $101.32

— Additional time up to three hours for a diagnostic interview (must be used with +99354)

CPT Add-On Code +99355 Reimbursement Rate (2020):  $100.33

CPT Add-On Code +99355 Reimbursement Rate (2021):  $96.31

Example CMS 1500 Form Coding for Extended Sessions

Please note you will need to make sure to fill in your own NPI in box 24J on the CMS-1500 form, in this example.

extended sessions billing cms 1500 example

Final Billing Suggestions

Consider all your services you provide (and at what times) when billing extended sessions. Make sure you’re asking about the right CPT codes when you’re doing your eligibility and benefits verification. Make sure to code your claims correctly for submission using the right add-on codes.

Ensure your EHR or claims management system is capable of billing these scenarios without interruption. Or look to hire out it all out .

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In the 2024 Final Rule, CMS changed the criteria for a “Substantive” portion for Shared/Split services. The substantive portion defines who gets to report the E/M service based on who met the criteria, remainder of the Split/Shared guidelines remain unchanged. You still need to be in the same group practice and the service has to occur on the same calendar day. Novitas has the Shared/Split guidelines on their page.

Substantive Portion Criteria :

A.  Either document the substantive portion of the (MDM), or

B.  Document that you spent >50% of the combined total time reported

  • Critical Care –  Substantive Portion =  >50% of the total time only.
  • Emergency Department – Substantive Portion =  MDM only.
  • Activities that contribute to the total time are the same as what was implemented by CPT for the office/clinic setting in 2021.
  • CMS delayed the implementation for using time only to determine the substantive portion.

The AAPC shared examples of documenting the substantive portion in their Updates Clarify Medicare Split/Shared article.

“I provided the substantive portion of the care of this patient. I personally performed the (MDM) for this encounter.”  Include documentation of the MDM to the extent needed to support the assigned E/M code.) “I provided a substantive portion of the care of this patient. I personally provided more than half of the (total time) dedicated to the treatment of this patient.” Include both provider times, whomever has more than half, may report the service.

Modifier -FS (Shared/Split E/M visit) must be appended to the E/M CPT code on Medicare claims.

There are several very informative fact sheets that you may find helpful out there. CodingIntel published one ( here ). You may need to create a login (free) to access it. I have also included our internal resources for your review below.

Shared/Split Resource Sheets:

  • Novitas Split/Shared Page
  • Transmittal 11288 Shared Visit Changes
  • Shared Prolonged Services (currently being updated)
  • Shared Critical Care Services
  • Shared Facility Setting E/M Services
  • Quick Tips Sheet
  • IM At-a-Glance News Blast
  • University of Chicago Billing Tip Sheet

Article revised 09/12/2023 with AAPC substantive portion language.

Contact for more information:.

[email protected]  or [email protected] . You can also reach out to your departmental compliance liaison listed under our “Meet the Team” tab.

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COMMENTS

  1. Coding for prolonged services: CPT and HCPCS codes

    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.

  2. Extend Prolonged Service Smarts With New Codes : E/M 2023

    For 2023, CPT® also deletes prolonged service codes +99354 and +99355. In their place, you'll now use +99417, as CPT® has increased its scope. You'll now be allowed to use it to report prolonged services with: 99245 (Office or other outpatient consultation for a new or established patient …) when the time meets or exceeds 55 minutes.

  3. Outpatient E/M Coding Simplified

    The AMA CPT committee developed code 99417 for prolonged visits, and Medicare developed code G2212. These are added in 15-minute increments in addition to codes 99205 or 99215.

  4. Prolonged physician services: Office and other outpatient E/M visits

    Effective January 1, 2021, CMS created HCPCS code G2212 for prolonged office/other outpatient evaluation and management (E/M) visits. HCPCS code G2212 is to be used for billing Medicare for prolonged office and outpatient E/M visits instead of CPT codes 99358, 99359 or 99417, for dates of service on and after January 1, 2021. Code descriptor

  5. Make Quick Work of Prolonged Care Coding

    CMS also created three new HCPCS Level II codes — G0316, G0317, and G0318 — to be reported in place of 99418 for prolonged hospital inpatient or observation care E/M services: G0316 may be reported in addition to 99223, 99233, and 99236 for inpatient and observation visits. Similar to 99418, the total time spent in applicable activities on ...

  6. Billing Prolonged Services with Direct Patient Contact

    There are four codes to choose from when billing for prolonged services with direct patient contact. They are based on whether the patient is in the office/outpatient setting, or if the patient is in an inpatient/observation setting. Report 99354 in addition to E/M codes 99201-99215, 99241-99245, 99324-99337, 99341-99350.

  7. Prolonged physician services: Hospital inpatient or observation care

    Prolonged services can be reported when time is used to select visit level, and the total practitioner time for the highest-level visit is exceeded by 15 or more minutes for medically reasonable and necessary services. HCPCS code G0316 should be listed separately in addition to CPT codes 99223, 99233, and 99236.

  8. PDF Code and Guideline Changes

    CPT codebook. The inclusion of time as an explicit factor beginning in CPT 1992 was done to assist in selecting the most appropriate level of E/M services. Beginning with CPT 2021, except for 99211, time alone may be used to select the appropriate code level for the office or other outpatient E/M services

  9. New prolonged service CPT code for 2021

    Billing, Coding & Payments | September 21, 2020. Beginning in 2021, there will be a new code for reporting prolonged services together with an office visit. The new code, CPT Code 99417, replaces CPT Codes 99354 and 99355. It can be used to report the total prolonged time with and without direct patient contact on the same day as an office visit.

  10. Specific criteria must be met to use prolonged services codes

    The visit lasts 75 minutes, of which over 50 minutes were spent on counseling and coordination of care. Report CPT codes 99215 and 99354. Coding tip: Because over 50% of the total face-to-face time was spent in counseling and coordination of care, time is the controlling factor. That means the time in the highest code in the code set must be ...

  11. PDF Evaluation and Management Services Reference Guide

    The guide provides real-world clinical examples of how to select the most appropriate CPT codes for inpatient and outpatient visit encounters (codes 99202-99215). ... CPT code 99417 is used to report prolonged services when the total time on the date of encounter of an outpatient service (99205, 99215, 99245) exceeds 15 minutes beyond the time ...

  12. PDF MLN906764 Evaluation and Management Services Guide 2023-08

    Split (or Shared) E/M Services. CPT Codes 99202-99205, 99212-99215, 99221-99223, 99231-99239, 99281-99285, & 99291-99292. A split (or shared) service is an E/M visit where both a physician and NPP in the same group each personally perform part of a visit that each 1 could otherwise bill if provided by only 1 of them.

  13. A Step-by-Step Time-Saving Approach to Coding Office Visits

    The new evaluation and management office visit coding rules have simplified many things but are still a lot to digest, especially when it comes to counting data. ... Prolonged services CPT (99417 ...

  14. How To Properly Report Prolonged Services Using 99417 or G2212

    by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT Feb 3rd, 2021. Prolonged Evaluation & Management codes underwent big changes in 2021, including the creation of a new prolonged code (), reportable only with codes 99205 or 99215.While Medicare has agreed to accept the AMA's CPT E/M coding changes, they have formulated an opinion contrary to how CPT calculates time specific to reporting this ...

  15. PDF Prolonged Services (Codes 99354

    99327 and the total duration of the direct face-to-face contact (including the visit) was 140 minutes. The physician bills CPT codes 99327, 99354, and one unit of code 99355. EXAMPLE 3 . A physician performed an office visit to an established patient that was predominantly counseling, spending 75 minutes (direct face-to-face) with the patient.

  16. What are the Changes to Prolonged Services Coding in 2023?

    New CPTProlonged Service Code: There is a new prolonged service code in 2023: +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 ...

  17. Understanding the long list of prolonged services in 2022 and ...

    Breaking down the prolonged services codes: +99417 and +G2212. These are the two codes likely to come up most frequently on audits for prolonged E/M services. Add-on code +99417 was created by CPT and relies on either 99215 or 99205 as the primary code. It becomes billable exactly one minute after the time threshold for 99215 or 99205 is ...

  18. Prolonged Service Code

    Prolonged Service Codes. CMS created HCPCS codes when billing Medicare for prolonged Evaluation and Management (E/M) services which exceeds the maximum time for the highest level (99205, 99215, 99223, etc.) E/M visit in each category by at least 15 minutes on the date of service. CMS prolonged service guidelines are different from the American ...

  19. Hard Facts of Coding Prolonged Services

    How to Use: Prolonged services are reported in addition to the primary evaluation and management (E/M) service performed at that visit. The primary E/M code must have a typical or specified time as designated in the CPT® codebook. Depending on the place of service, 99354 or 99356 is used to report the first hour of prolonged service on a given ...

  20. Prolonged physician services: Nursing facility E/M visits

    Beginning January 1, 2023, prolonged NF services are reported using Medicare-specific coding (HCPCS code G0317). Prolonged Services can be reported when time is used to select visit level, and the total time for the highest-level visit is exceeded by 15 or more minutes for services that are reasonable and medically necessary.

  21. Three Things To Know When Reporting Prolonged Services in 2023

    The Evaluation and Management (E/M) changes made in 2021 and again in 2023 brought about new CPT codes and guidelines for reporting prolonged services. Just as Medicare disagreed with CPT in the manner in which prolonged service times should be calculated, they did so again with the new 2023 changes. Here are three things you should know when reporting prolonged services for all E/M services.

  22. How to Bill Extended Sessions & Prolonged Services for Mental Health

    Billing Extended Sessions for Individual Therapy. It's important to note that if you are seeing a client for 60 minutes or under, make sure to bill using CPT codes 90832, 90834, or 90837 alone. Do not bill using add-on codes if sessions are not extended. Services performed outside of business hours.

  23. Prolonged physician services: Home or residence visits

    Prolonged home or residence E/M visits (HCPCS code G0318) should be billed instead of CPT codes 99358, 99359 or 99417. HCPCS code G0318 should be listed separately in addition to CPT codes 99345 or 99350. You should not report G0318 with other primary services. Only physicians and NPPs who provide services to Medicare beneficiaries in the ...

  24. Shared/Split Visits: 2024 Rules

    Shared/Split Visits: 2024 Rules. In the 2024 Final Rule, CMS changed the criteria for a "Substantive" portion for Shared/Split services. The substantive portion defines who gets to report the E/M service based on who met the criteria, remainder of the Split/Shared guidelines remain unchanged. You still need to be in the same group practice and the service has to occur on the same calendar day.

  25. CPT® 2024 Brings More E/M Changes

    For example, 99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making … has a current time range of 15-29 minutes. Beginning Jan. 1, 2024, the provider must meet or exceed 15 minutes of total service time before you can bill this code by time.