Author: Keisha Wilson CCS, CPC, CRC, CPB, CPMA, AAPC Approved Instructor
Some providers have never heard of or utilized prolonged service codes, and others have been utilizing and billing prolonged services for many years. In recent years, AMA (American Medical Association) has added, deleted and revised several codes to ensure accurate coding and reporting of prolonged service when a physician, other qualified healthcare providers and clinic staff spend additional time above and beyond the E/M (Evaluation and Management) service level.
When prolonged time (additional time spent) occurs, the appropriate prolonged services code may be reported once guidelines are met. The total time on the date of the encounter spent caring for the patient and speaking with the caregiver/family member should be documented in the medical record when it is used as the basis for code selection. It cannot be used when selecting an E/M service level with MDM (Medical Decision Making). Total time spent in prolonged services should be noted, and supporting documentation on what service/activities were provided that took the additional time.
CMS (Centers for Medicare & Medicaid Services) commercial payers have often asked for additional documentation requests (ADR) to be submitted for review before they pay for the prolonged services. In addition, the OIG has also added prolonged service to their work plan several times, which means codes must be documented and reported compliantly.
Per AMA revised guidelines, physician or other qualified health care professional time includes the following activities, when performed:
- preparing to see the patient (e.g., review of tests)
- obtaining and reviewing the 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 records
- independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
- care coordination (not separately reported)
Time does not include the following:
- the performance of other services that are reported separately
- travel
- teaching that is general and not limited to the discussion that is required for the management of a specific patient
AMA guidelines state: Time is not a descriptive component for the emergency department levels of E/M services because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time.
What Has Changed in 2023
Deleted Codes as of 1/1/2023
- Deletion of Prolonged Services E/M codes 99354-99357
Revised Codes as of 1/1/2023
- Revision of guidelines for Prolonged Services E/M codes 99358, 99359, 99415, 99416
- Revision of Prolonged Services E/M code 99417 and guidelines
New Codes as of 1/1/2023
- New Prolonged Services E/M code 99418 and guideline (AMA)
- New Prolonged Services G0316 – G0318 (CMS)
AMA New 99418 vs CMS G0316 – G0318
Prolonged service code 99418 is used for inpatient or observation E/M (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 99418 in 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 (99223) and subsequent inpatient and observation codes (99233), inpatient consultation (99255), and initial (99306) and subsequent (99310) nursing facility services.
The following services cannot be used with Prolonged Service codes:
- Discharge services 99238, 99239, 99315, 99316. It may not be used with
- Emergency Department codes.
- Psychotherapy services
- Non- face-to-face prolonged codes
- The full 15 minutes is required, and time must have been used to select the level of service.
As with the 2021 E/M outpatient changes Prolonged Time, CMS is not recognizing the new CPTcode 99418 and has created new HCPCS G codes (G0316 – G0318) used instead for Medicare patients. The CMS time threshold to report prolonged codes differs from AMA’s. As of 2023, CMS allows the count for starting the time clock for some prolonged codes to start the day before the visit, the date of the visit, or 3 – 7 days after the visit depending on service location. Providers, other qualified healthcare professionals, clinal staff, coders, billers, auditors, IT professionals, and administrators should review CMS guidelines and threshold charts in reporting time accurately. Time should be carefully tracked, monitored and reported, especially with new changes as significant as this. Risk needs to be mitigated as much as possible.
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.
CMS issued a notice on March 14, 2023, correcting several technical errors in the 2023 MPFS final rule published on November 18, 2022. Corrections have been made to calculating time thresholds for reporting E/M prolonged Inpatient/Observation services code G0316. The update has also been made to their “Pub 100-04 Medicare Claims Processing Manual”
- 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
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 and 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.
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 and 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.
Detailed information, as well as the grind below, can be found in CMS 2023 Final Rule Table 24:
Revision of 99417
As of January 1, 2023, the AMA removed the following words from the code descriptor but kept the prior guidelines from 2021 E/M revision for 99417 “beyond the minimum required time” and now states: “Prolonged outpatient 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 outpatient Evaluation and Management service).
- Use 99417 in conjunction with 99205, 99215, 99245, 99345, 99350, 99483
- Do not report 99417 on the same date of service as 90833, 90836, 90838, 99358, 99359, 99415, 99416
- Do not report 99417 for any time unit less than 15 minutes
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.
There are additional revisions to code sets 99415, 99416 (Prolonged Clinical Staff Services with Physician or Other Qualified Health Care Professional Supervision) as well as 99358, 99359 (Prolonged Service on Date Other Than the Face-to-Face Evaluation and Management Service Without Direct Patient Contact) which we will address in part two blog post of prolonged service codes. In the interim, review the attached AMA document and the CPT book for further coding guidance.
2023 although just begun, has already brought many changes to the AMA guidelines and CMS final rule. Understanding these changes will take time, just as it did in 2021. To keep abreast of the changes, the best thing is to continuously review and understand the guidelines, attend webinars (KW Advanced Consulting has some coming soon), and review FAQs posted on AMA and NGS websites. Other MACs (depending on your location) review payer policies. As well as creating tip sheets or pocket cards, all these tools are resources that will help you acclimate to the changes to ensure you report the most accurate code. For more on documenting total time, review our other blog post, “Documenting Total Time.“
To schedule training on documentation and coding guidelines for your organization or private practice providers or schedule a chart review email us today at info@kwadvancedconsulting.com, schedule a call or visit the website and fill out the “contact us” form.
Resources:
https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
https://www.ama-assn.org/system/files/correction-cpt-e-m-2023.pdf
https://www.cms.gov/files/document/r11842cp.pdf
Blog Updated: 3/21/2023
