Accurate Use of Prolonged Services CPT Code

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Accurate Use of Prolonged Services CPT Code

• Billing for Prolonged Services
• Physicians have been billing prolonged services
  for a long time but in recent years the number of
  codes involved has grown and their requirements
  have changed, making them a potentially risky
  area for providers. In this article, we shared
  coding guidelines for the accurate use of
  prolonged services CPT code. Before we dive in,
  its worth noting 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. Agency
  also mentioned that they will determine whether
  Medicare payments to physicians for prolonged E/M
  services were reasonable and made in accordance
  with Medicare requirements.
• Coding Guidelines for Prolonged Services
• Most of the time, private insurance will
  separately reimburse physicians or other
  qualified healthcare professionals for Prolonged
  Services when reported in conjunction with
  companion Evaluation Management (E/M) codes or
  other services.

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Accurate Use of Prolonged Services CPT Code

• In accordance with The Centers for Medicare and
  Medicaid Services (CMS) and American Medical
  Association (AMA), Prolonged Services without
  Direct Patient Contact (CPT codes 99358-99359)
  will not be separately reimbursed when reported
  with Care Management (CM) CPT codes 99484, 99487,
  99489, 99490, 99492-99494, G2058 and Transitional
  Care Management (TCM) CPT codes 99495 and 99496.
• Private insurance carriers reimburse Prolonged
  Services when reported with E/M codes in which
  time is a factor in determining the level of
  service in accordance with CPT and or HCPCS
  guidelines.
• Physicians or other qualified health care
  professionals should report only Prolonged
  Services beyond the typical duration of the
  service on a given date, even if the time spent
  by the physician or other qualified health care
  professional is not continuous.
• Providers should not include the time devoted to
  performing separately reportable services when
  determining the amount of prolonged services
  time. For example, the time devoted to performing
  cardiopulmonary resuscitation (CPT code 92950)
  should not be included in prolonged services
  time. Prolonged service of less than 30 minutes
  total duration on a given date is not separately
  reported because the work involved is included in
  the total work of the evaluation and management
  codes.
• According to CPT and HCPCS, prolonged service
  codes 99354-99357, 99359, 99415-99416, 99437,
  99439, and G0513-G0514, G2212 are considered
  add-on codes and should not be reported without
  the appropriate primary code.

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Accurate Use of Prolonged Services CPT Code

• Medicare has assigned a status indicator of
  invalid to code 99417 and developed an HCPCS code
  to replace it, G2212.
• Prolonged services for labor and delivery are not
  separately reimbursable services. As described in
  the American Congress of Obstetricians and
  Gynecologists (ACOG) coding guidelines, prolonged
  services are not reported for services that do
  not have a time component such as labor and
  delivery management.
• In accordance with CMS and the AMA, Prolonged
  Services without Direct Patient Contact (CPT
  codes 99358-99359) will not be separately
  reimbursed when reported with CM CPT codes
  99417,99484, 99487, 99489, 99490, 99492- 99494,
  G2058, and TCM CPT codes 99495 and 99496.
• According to CPT, modifier 25 may be appended to
  prolonged services codes if there is adequate
  supporting documentation that describes the
  service provided and indicates the service is
  significant and separately identifiable from
  another service or procedure on the same date of
  service.
• Prolonged Services CPT Code
• 99417 and G2212

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Accurate Use of Prolonged Services CPT Code
Add-on code 99417 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 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, its important to verify applicable payer
policies on which code to use. Remember that
these prolonged services include non-face-to-face
time spent before or after direct patient care if
those times can be directly attributed to the
patient encounter. 99415 and 99416
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Accurate Use of Prolonged Services CPT Code
These two codes are used with office/outpatient
E/M codes but are not limited to the level 5
codes only. These codes were revised in the year
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 time in direct patient contact under
physician supervision. 99354 and 99355 Prior
to the year 2021, these codes were used in
conjunction with office/outpatient E/M codes when
prolonged time thresholds were met. After the
year 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.
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Accurate Use of Prolonged Services CPT Code
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 also
revised in the year 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 patients bedside as
well as on the patients 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). Please note
that the time spent on the date of service does
not have to be continuous. 99358 and
99359 These two 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.
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Accurate Use of Prolonged Services CPT Code
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 providers time spent on the date of service,
the time before and after direct patient contact
can be included. Medical Billers and Coders
(MBC) is a leading medical billing company
providing complete revenue cycle services. We
hope this article has given you a good
understanding of the accurate use of prolonged
services CPT code. To know more about our billing
and coding services, contact us
at info_at_medicalbillersandcoders.com/ 888-357-3226
. CPT Copyright 2022 American Medical
Association. Reference National Alliance of
Medical Auditing Specialists