May 28, 2021 | Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content, innoviHealth
Prolonged services codes were created to capture reimbursement for time spent with a patient that goes beyond the typical time associated with the primary service. We’re all aware of those patients that, unexpectedly, require so much prolonged provider attention that the entire schedule is thrown off. Should providers receive additional compensation for these prolonged services? Absolutely, but caution must be taken in assigning these codes to ensure the documentation supports these add-on codes and any associated reimbursement.
Prior to 2021, it was uncommon to see providers frequently reporting prolonged services because the code requirements were difficult to meet and often were not properly documented. However, in 2021, CPT® and HCPCS codes were added, code descriptions revised, and guidelines altered, allowing providers to report some prolonged services beginning as early as 15 minutes beyond the associated service time. To determine whether the service qualified for the add-on prolonged service code, consider the documentation requirements for doing so, which include:
- Location (e.g., office, inpatient, observation)
- Date of the prolonged service (before, during, or following the E/M encounter)
- Provider (physician, QHP, clinical staff)
- Type of patient contact (with, without, or with/without)
- Summary of services performed
- Start/stop or total time
This tip will focus on the proper use of 99417 and G2212 as they relate to Office and Other Outpatient Prolonged E/M Services (99205-99215).
New Prolonged Service Codes 99417 and G2212
Prior to 2021, the codes used to report prolonged E/M services in the office or other outpatient setting were 99354 (for the first hour) and 99355 (for each additional 30 minutes of prolonged services), which were also reported for psychotherapy prolonged services (office and outpatient), consultations, and other specific outpatient settings.
When CPT published changes to the 99202-99215 codes for Office and Other Outpatient E/M services, they created a new prolonged E/M services code (99417) just for 99205 and 99215. While Medicare announced the acceptance of the CPT changes, they did not agree with all of the prolonged services guidelines, so they created their own code (G2212). Specifically, CPT guidelines begin counting the 15 minutes of prolonged services time once provider time has exceeded the lower time in the range for 99205 or 99215 and Medicare guidelines require counting to begin once the upper time in the range has been exceeded. (See the table at the end of this article for details)
Ensure Criteria for the Primary Code (99205 or 99215) is Met
While calculating the time spent by a physician/QHP is important, it is more important that we first identify if the documentation supports a 99205 or 99215 based on medical necessity by checking the following:
- Did the provider document the patient’s condition(s), illness(es), or injury(ies) as having a high risk of mortality or morbidity?
- Do the details of the report support 99205 or 99215 for medical necessity?
If both are not met, then reporting prolonged services is NOT an option, as 99417 and G2212 can only be reported with primary codes 99205 and 99215. If the service only qualifies for 99204, then the additional time spent by the provider is not reimbursable/reportable. I’m sure you look forward to having that discussion with your providers, right?
Be sure to include the role of medical necessity in any provider training, especially as it pertains to 99205 and 99215, and be sure to share the CPT guidance noted in the risk column of the tables showing examples associated with 99205 and 99215.
Documentation Requirements and Time Limits
The following documentation requirements must be met to qualify for prolonged services reporting:
- Time must be documented (start/stop or total time based on payer guidelines)
- Summary of how time was spent (e.g., medication or risk review, counseling)
- ONLY physician/QHP time on the day of the encounter is counted
- Time spent on separately reportable services (e.g., minor procedures, professional interpretation of a test) CANNOT be counted towards E/M or prolonged services coding
The following tables are helpful in identifying the time associated with CPT and Medicare Prolonged Services reporting:
| CPT Prolonged Services (99417) | ||
| Primary Code | Total Minutes | Primary + Add-On x Units |
| 99205 | 60-74 | 99205 only |
| 75-89 | 99205 + 99417 x 1 unit | |
| 90-104 | 99205+99417 x 2 units | |
| 99215 | 40-54 | 99215 only |
| 55-69 | 99215 + 99417 x 1 unit | |
| 70-84 | 99215+99417 x 2 units | |
| Medicare Prolonged Services (G2212) | ||
| Primary Code | Total Minutes | Primary + Add-On x Units |
| 99205 | 60-88 | 99205 only |
| 89-103 | 99205+G2212 x 1 unit | |
| 104-118 | 99205+G2212 x 2 unit | |
| 99215 | 40-68 | 99215 only |
| 69-83 | 99215+G2212 x 1 unit | |
| 84-98 | 99215+G2212 x 1 unit | |
