November 25, 2022 | By Grant Huang, CPMA, CPC
It’s been two years since CMS collaborated with the AMA to revamp Evaluation & Management (E&M) coding guidelines, including a rework of prolonged services codes in the office/outpatient setting. This process culminated in a disagreement between the AMA’s CPT manual and CMS’ fee schedule final rule, with CPT using add-on code +99417 for office/outpatient prolonged services versus CMS creating its own code, +G2212. The CMS code also operates on a slightly different time scale than +99417, leaving coders and auditors with the dreaded “one rule for CPT, a different rule for Medicare” dynamic that can only complicate and prolong – pun intended – the coding process.
Now, in 2023, we are set to see this dynamic again, with one rule for CPT and a different for Medicare, this time when it comes to inpatient prolonged services. Here’s what you need to know for the New Year:
- Primary code/add-on code structure. Like the existing outpatient/office prolonged service codes, the inpatient prolonged service codes for 2023 are add-on codes that require a primary code to be billed. The primary codes are the highest-level inpatient/facility codes within each code range, e.g. 99223 for initial hospital/observation care.
- Meet +99418, CPT’s one-size-fits-all solution, except for home/residence services. CPT will use newly minted add-on code +99418 (formerly known under the placeholder “+993X0”) for all inpatient prolonged services. This means when the primary code is 99223, 99233, 99236, 99255, 99306, or 99310, CPT says to use add-on code +99418.
- Medicare has 3 different add-on codes: +G0316, +G0317, +G0318. Selection of the right code is based on the type of primary code as well as time requirements being met. +G0316 is prolonged hospital/observation services, and is used when the primary code is 99223, 99233, 99236, or 99255. +G0317 is prolonged nursing facility services and is used when the primary code is 99306 or 99310. Finally, +G0318 is prolonged home/residence services and is used when the primary code is 99345 or 99350.
- Different start times for CPT vs. Medicare. The time for supporting units of CPT’s add-on code begins immediately after the maximum time is met for the primary code. For Medicare, the time for supporting units of their add-on codes does not begin until a full 15-minute period after the maximum time is met for the primary code. The midpoint rule does NOT apply for either CPT or Medicare, a full 15-minute block is required for each additional unit of the add-on codes. Example: Initial nursing facility care code 99306 is reported with a total time of 90 minutes. The maximum time to support 99306 is 45 minutes, which means we have an extra 45 minutes of prolonged service time. For CPT, this comes out to 99418 x3. For Medicare, G0317 is the code for nursing facility prolonged services. Medicare also requires 15 minutes to elapse after the maximum time of the primary code before counting prolonged service time, so 45 – 15 = 30 minutes prolonged service time, coming out to G0317 x2.
- CPT says to use +99417 for prolonged home/residence services. To add one final wrinkle, the 2023 CPT manual explicitly states that +99417 and not +99418 is to be used when the primary code is 99345 or 99350, the highest-level home/residence service codes. This language is not present in the 2022 CPT manual, because the consolidation of home visit services is new to 2023.
Preparing for 2 sets of rules
If you have to code for and/or audit prolonged services, hopefully the experience dealing with CPT-specific and Medicare-specific rules in the outpatient/office setting in 2021 and 2022 has given you some familiarity with handling two competing sets of rules. Take these three steps to prepare for even more changes to prolonged services in the inpatient/facility settings in 2023:
- Educate providers on time documentation. This means not just reminding providers to document time, but also following best-practice guidance to include a summary of what the time was spent on. Such a summary is not required explicitly by CPT, but will help support medical necessity and provide safeguards when the inevitable prolonged service audits come. Also, remember that the 2023 E&M guidelines include a more flexible definition of what sorts of non-face-to-face activities by the billing provider can be counted towards the time required for the visit, including time spent before and after the visit on the same date of service. Educate providers on this important change.
- Create cheat sheets with code-specific time examples for CPT and Medicare. To speed up coding and auditing, create cheat sheets that list the times for all the primary codes in the inpatient/facility settings, as well as which G-code to use for Medicare. Include examples, like the one above for 99306, to help coders and auditors understand the arithmetic involved.
- Begin internal audits quickly in 2023 to catch any errors early. Finally, after the new codes take effect, don’t wait too long before conducting internal audits to see if they are being correctly billed. With changes of this scope to something as high-profile (to payers) as prolonged services, it’s better to catch any potential mistakes early on and fix them early on, rather than waiting for them to accumulate.
While it’s always cumbersome to have to deal with two sets of payer rules for the same exact type of service, planning ahead, educating providers, and auditing early will help ensure you stay compliant with them in 2023.
Your next steps:
- Contact NAMAS for information about customized staff and provider training.
- Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
- Subscribe to the NAMAS YouTube channel for more auditing and compliance tips!
NAMAS is a division of DoctorsManagement, LLC, a premier full-service medical consulting firm since 1956. With a team of experienced auditors and educators boasting a minimum of a CPC and CPMA certification and 10+ years of auditing-specific experience, NAMAS offers a vast range of auditing education, resources, training, and services. As the original creator of the now AAPC-affiliated CPMA credential, NAMAS instructors continue to be the go-to authorities in auditing. From DOJ and RAC auditors to CMS and Medicare Advantage Auditors to physician and hospital-based auditing professionals, our team has educated them all. We are proud to have helped so many grow and excel in the auditing and compliance field.
Looking to start up a medical practice or grow your existing practice? Contact our parent company, DoctorsManagement.