Have you ever had a patient spend more time with you than you expected? Do you understand exactly which codes to report and the rules that govern them in exchange for receiving better reimbursement? Prolonged Service codes were specially designed for this purpose, but you must strictly adhere to the documentation and coding guidelines to avoid complications. When an Evaluation and Management code has been reported as the primary code, are these “add-on” codes reportable? There are three Prolonged Service codes, but we will emphasize codes 99354-99357 here.
The most common professional services that a medical billing and coding company aids physicians in reporting claims are evaluation and management (E/M) codes. The rules for documenting these services are re-evaluated and revised routinely regarding patient safety and reducing administrative burden. New codes have been added to the bill for extended services that involve direct and indirect patient contact and are provided in a variety of settings in addition to the usual evaluation and management services.
Things to know about prolonged evaluation and management services
The Importance of Time in E/M Service Level Selection
Time is critical in determining the best level of E/M services. Except for 99211 (office or another outpatient visit for the E&M of an established patient that does not require the presence of a physician), time alone is used to select the appropriate code level for office or other outpatient E/M services codes beginning with CPT 2021.
Because time is used in different categories of services, the American Medical Association (AMA) recommends that each category’s instructions be reviewed. When time is used to report E/M service codes, the best level of E/M services is chosen depending on time.
These guidelines apply to E/M services requiring a one-on-one meeting with a physician or other qualified healthcare professionals. The appropriate comprehensive services code should be reported when a prolonged period occurs.
The AMA defines physician/other qualified health care professional time along with the following activities:
Gearing up to see the patient.
Obtaining and reviewing a separate accepted history.
Conducting a medically appropriate examination.
Evaluation counseling and educating the patient/family/caregiver.
Ordering medications, tests, or procedures.
Communicating with other health care professionals.
Independently interpreting results and displaying results to the patient/family.
For 2021, two new extended service codes are specific to E/M codes 99205 and 99215
New Comprehensive Feature Codes
CPT code 99417 can be reported for every 15 minutes of extended care provided on the same day that exceeds the maximum time listed for E/M codes 99205 and 99215.
99417 – Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure adopted using total time, requiring whole time with or without direct patient contact beyond the usual service on the date of the immediate assistance, every 15 minutes of the entire time.
The Centers for Medicare and Medicaid Services (CMS) created HCPCS code G2212, intended to report prolonged services specific to 99205 and 99215.
G2212 – Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure, as calculated by total time on the date of service.
Points to keep in mind While Reporting on Prolonged Services
CPT code 99417 and HCPCS code G2212 may only be reported in conjunction with level 5 visit codes 99205 or 99215 if the codes were picked purely based on time and not medical decision-making.
Check the payer’s strategy for appropriate reporting guidelines:
When billing payers other than Medicare, use CPT code 99417. This code should only be billed under 99205 or 99215 and represents an additional 15 minutes beyond the office visit code’s minimum time
Each additional 15 minutes can be billed in multiple units. Other time of fewer than 15 minutes is not required to be disclosed.
G2212 is unique to Medicare and payers who adhere to Medicare guidelines. CPT Codes 99205 or 99215 should be reported for each additional 15 minutes of extended service beyond the maximum time.
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