Part III A Deeper Dive into Prolonged Services:
G2212
- New code for Medicare
- Prolonged office E/M beyond maximum required time of primary procedure which has been selected using total time
- On date of primary service
- Each 15 min of total time
- Replaced the 99417
Example:
- 69-year-old male new patient with severe chronic obstructive pulmonary disease, congestive heart failure, hypertension
- Extensive medical history with multiple medical issues collected, including review of prior treatment, tests, old medical records reviewed
- Exam performed
- Lengthy discussion about multisystem illness severity and prognosis
- Counseling on smoking, diet, medication compliance
- Refer to pulmonary medicine and cardiology subspecialist after tests received
- Total time spent with the patient is 92 minutes
- Which E/M code(s) should be reported for this case study?
- 99205 X 1 G2212
G2211
- New Code Medicare
- Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition.
- Add on code, list separately in addition to office/outpatient evaluation and management visit, new or established (99202-99215)
- Can be used by any specialty
Prolonged Service with Direct Patient Contact (Except with Office or Other Outpatient Services)
Codes 99354-99357 are used when a physician or other qualified health care professional provides prolonged service(s) involving direct patient contact that is provided beyond the usual service in either the inpatient, observation or outpatient setting, except with office or other outpatient services (99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215).
Direct patient contact is face-to-face and includes additional non-face-to-face services on the patient’s floor or unit in the hospital or nursing facility during the same session. This service is reported in addition to the primary procedure. Appropriate codes should be selected for supplies provided or other procedures performed in the care of the patient during this period.
Codes 99354-99355 are used to report the total duration of face-to-face time spent by a physician or other qualified health care professional on a given date providing prolonged service in the outpatient setting, even if the time spent by the physician or other qualified health care professional on that date is not continuous. Codes 99356-99357 are used to report the total duration of time spent by a physician or other qualified health care professional at the bedside and on the patient’s floor or unit in the hospital or nursing facility on a given date providing prolonged service to a patient, even if the time spent by the physician or other qualified health care professional on that date is not continuous.
Time spent performing separately reported services other than the E/M or psychotherapy service is not counted toward the prolonged services time.
Code 99354 or 99356 is used to report the first hour of prolonged service on a given date, depending on the place of service.
Either code should be used only once per date, even if the time spent by the physician or other qualified health care professional is not continuous on that date. Prolonged service of less than 30 minutes total duration on a given date is not separately reported.
Code 99355 or 99357 is used to report each additional 30 minutes beyond the first hour, depending on the place of service. Either code may also be used to report the final 15-30 minutes of prolonged service on a given date. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.
The use of the time-based add-on codes requires that the primary evaluation and management service have a typical or specified time published in the CPT codebook.
For E/M services that require prolonged clinical staff time and may include face-to-face services by the physician or other qualified health care professional, use 99415, 99416. Do not report 99354, 99355 with 99415, 99416, 99XXX.
For prolonged total time in the Office or Other Outpatient Services, use 99XXX.
The following table illustrates the correct reporting of prolonged physician or other qualified health care professional service with direct patient contact in the inpatient or observation setting beyond the usual service time.
Face to Face Prolonged Care Codes
99354, 99355
- Still active, billable codes, not reportable with codes 99202–99215
- Reported for prolonged care services with: - Psychotherapy codes 90837, 90847
- Domiciliary care codes 99324—99337
- Home visit codes 99341—99350
- Cognitive assessment code 99483
99354 Prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service; first hour (List separately in addition to code for outpatient Evaluation and Management or psychotherapy service, except with office or other outpatient services [99202-99215])
(Use 99354 in conjunction with 90837, 90847, 99241-99245, 99324-99337, 99341- 99350, 99483)
(Do not report 99354 in conjunction with 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99415, 99416, 99XXX)
99355 each additional 30 minutes (List separately in addition to code for prolonged service)
(Use 99355 in conjunction with 99354)
(Do not report 99355 in conjunction with 99202, 99203, 99204, 99205, 99211, 99212,
99213, 99214, 99215, 99415, 99416, 99XXX)
99356 Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient or observation Evaluation and Management service)
(Use 99356 in conjunction with 90837, 90847, 99218-99220, 99221-99223, 99224- 99226, 99231-99233, 99234-99236, 99251-99255, 99304-99310)
99357 each additional 30 minutes (List separately in addition to code for prolonged service)
(Use 99357 in conjunction with 99356)
Prolonged Service Without Direct Patient Contact Non-Face to Face
- 99358-99359
- Not reportable on same date of service as 99202—99215
- Non-face-to-face prolonged care are included in total time on the day of office/outpatient visit, if performed by same provider
- Not reportable with CCM or TCM
Codes 99358 and 99359 are used when a prolonged service is provided that is neither face-to-face time in the outpatient, inpatient, or observation setting, nor additional unit/floor time in the hospital or nursing facility setting. Codes 99358, 99359 may be used during the same session of an evaluation and management service, except office or other outpatient services (99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215). For prolonged time without direct patient contact on the date of office or other outpatient services, use 99XXX. Codes 99358, 99359 may also be used for prolonged services on a date other than the date of a face-to face encounter.
This service is to be reported in relation to other physician or other qualified health care professional services, including evaluation and management services at any level. This prolonged service may be reported on a different date than the primary service to which it is related. For example, extensive record review may relate to a previous evaluation and management service performed at an earlier date. However, it must relate to a service or patient where (face-to-face) patient care has occurred or will occur and relate to ongoing patient management.
Codes 99358 and 99359 are used to report the total duration of non-face-to-face time spent by a physician or other qualified health care professional on a given date providing prolonged service, even if the time spent by the physician or other qualified health care professional on that date is not continuous. Code 99358 is used to report the first hour of prolonged service on a given date regardless of the place of service. It should be used only once per date.
Prolonged service of less than 30 minutes total duration on a given date is not separately reported.
Code 99359 is used to report each additional 30 minutes beyond the first hour. It may also be used to report the final 15 to 30 minutes of prolonged service on a given date.
Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately. Do not report 99358, 99359 for time without direct patient contact reported in other services such as care plan oversight services (99339, 99340, 99374-99380), chronic care management by a physician or other qualified health care professional (99491), home and outpatient INR monitoring (93792, 93793), medical team conferences (99366-99368), interprofessional telephone/internet/electronic health record consultations (99446-99452), or on-line digital evaluation and management services (9X0X1, 9X0X2, 9X0X3).
99358 Prolonged evaluation and management service before and/or after direct patient care; first hour
99359 each additional 30 minutes (List separately in addition to code for prolonged service)
(Use 99359 in conjunction with 99358)
(Do not report 99358, 99359 on the same date of service as 99XXX)
(Do not report 99358, 99359 during the same month with 99484, 99487-99489, 99490, 99491, 99492, 99493, 99494)
(Do not report 99358, 99359 when performed during the service time of codes 99495 or 99496, if reporting 99495 or 99496)
Prolonged Clinical Staff Services with Physician or Other Qualified Health Care Professional Supervision
Codes 99415, 99416 are used when a prolonged evaluation and management (E/M) service is provided in the office or outpatient setting that involves prolonged clinical staff face-to-face time beyond the typical face-to-face time of the E/M service, as stated in the code description. The physician or qualified health care professional is present to provide direct supervision of the clinical staff. This service is reported in addition to the designated E/M services and any other services provided at the same session as E/M services.
Codes 99415, 99416 are used to report the total duration of face-to-face time spent by clinical staff on a given date providing prolonged service in the office or other outpatient setting, even if the time spent by the clinical staff on that date is not continuous. Time spent performing separately reported services other than the E/M service is not counted toward the prolonged services time.
Code 99415 is used to report the first hour of prolonged clinical staff service on a given date. Code 99415 should be used only once per date, even if the time spent by the clinical staff is not continuous on that date. Prolonged service of less than 45 minutes total duration on a given date is not separately reported because the clinical staff time involved is included in the E/M codes. The typical face-to-face time of the primary service is used in defining when prolonged services time begins. For example, prolonged clinical staff services for 99214 begin after 25 minutes, and 99415 is not reported until at least 70 minutes total face-to-face clinical staff time has been performed. When face-to-face time is noncontiguous, use only the face-to-face time provided to the patient by the clinical staff.
Code 99416 is used to report each additional 30 minutes of prolonged clinical staff service beyond the first hour. Code 99416 may also be used to report the final 15-30 minutes of prolonged service on a given date. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.
Codes 99415, 99416 may be reported for no more than two simultaneous patients. The use of the time- based add-on codes requires that the primary E/M service has a typical or specified time published in the CPT code set.
For prolonged services by the physician or other qualified health care professional, see 99354, 99355, 99XXX. Do not report 99415, 99416 with 99354, 99355, 99XXX.
Facilities may not report 99415, 99416.
99415 Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour (List separately in addition to code for outpatient Evaluation and Management service)
(Use 99415 in conjunction with 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215)
(Do not report 99415 in conjunction with 99354, 99355, 99XXX)
99416 each additional 30 minutes (List separately in addition to code for prolonged service)
(Use 99416 in conjunction with 99415)
(Do not report 99416 in conjunction with 99354, 99355, 99XXX)
The Total Duration of Prolonged Services Table illustrates the correct reporting of prolonged services provided by clinical staff with physician supervision in the office setting beyond the initial 45 minutes of clinical staff time:
Prolonged Service with or without Direct Patient Contact on the Date of an Office or Other Outpatient Service
Code 99XXX is used to report prolonged total time (ie, combined time with and without direct patient contact) provided by the physician or other qualified health care professional on the date of office or other outpatient services (ie, 99205, 99215). Code 99XXX is only used when the office or other outpatient service has been selected using time alone as the basis and only after the total time of the highest-level service (ie, 99205 or 99215) has been exceeded. To report a unit of 99XXX, 15 minutes of additional time must have been attained. Do not report 99XXX for any additional time increment of less than 15 minutes.
Time spent performing separately reported services other than the E/M service is not counted toward the time to report 99205, 99215 and prolonged services time.
For prolonged services on a date other than the date of a face-to-face encounter, including office or other outpatient services (99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215), see 99358, 99359. For E/M services that require prolonged clinical staff time and may include face-to-face services by the physician or other qualified health care professional, see 99415, 99416. Do not report 99XXX in conjunction with 99354, 99355, 99358, 99359, 99415, 99416.
Prolonged services of less than 15 minutes total time on the date of the office or other outpatient service (ie, 99205, 99215) is not reported.
⚫ 99XXX
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 99XXX in conjunction with 99205, 99215)
(Do not report 99XXX in conjunction with 99354, 99355, 99358, 99359, 99415, 99416) (Do not report 99XXX for any time unit less than 15 minutes)
Prolonged Visit Decision Tree:
CAUTION-
When coding based on time
– Sum the two times together
– Time together should only be counted once – You cannot count same minute twice
Incident to/Split Share:
You may not be aware of the potential problems posed by new code +99417 (Prolonged office or other outpatient evaluation and management service(s) …; each 15 minutes …). Per CPT® guidelines, you can report +99417 when the total time exceeds the minimum time of 99205 (…. 60-74 minutes…) or 99215 (… 40-54 minutes…) by 15 minutes. For example, per CPT®, you may report a unit of +99417 when the total time spent on the date of service in conjunction with a 99205 reaches 75 minutes.
However, in the 2021 PFS proposed rule, “CMS’ instructions are not the same as the CPT® instructions. CMS is proposing to permit +99417 only when the maximum times of 99205 or 99215 have been exceeded by 15 minutes, or when the times for the codes hit 89 minutes or 69 minutes, respectively,” explains Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.
To see if this discrepancy gets resolved, once again you will have to monitor the 2021 PFS final rule.
Note: Please review all content and items with your Biller and if you have any Questions please reach out to me or my team for any details or clarification. Our Certified Coders on Staff may be able to help you navigate these changes.
