April 22, 2022 | By Grant Huang, CPMA, CPC
Prolonged services have been around for a long time – no pun intended – but in recent years the number of codes involved has grown and their requirements have changed, making them a potentially risky area for providers. For this reason, auditors should take the time to brush up on the types of prolonged services there are to choose from. In this tip, we will do just that.
Before we dive in, it’s worth nothing 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. “We will determine whether Medicare payments to physicians for prolonged E/M services were reasonable and made in accordance with Medicare requirements.”
The OIG was referring specifically to the add-on codes associated with office/outpatient E/M codes 99202-99215, but in 2022 and beyond we have to contend with significant changes to some existing prolonged services codes as well as new add-on codes to be used with 99202-99215. Please refer to the table below for a complete list.
|CPT code(s)||Short descriptor|
|99417, G2212*||Prolonged office/outpatient E/M service /w or w/o direct patient contact|
|99415, 99416**||Prolonged clinical staff time during office/outpatient E/M, direct patient contact|
|99354, 99355**||Prolonged service(s), outpatient setting /w direct patient contact|
|99356, 99357**||Prolonged service(s), inpatient or observation setting, unit/floor time|
|99358, 99359||Prolonged service(s) before or after direct patient care|
|*Implemented in 2021; **Revised in 2021|
Breaking down the prolonged services codes:
- +99417 and +G2212. These are the two codes likely to come up most frequently on audits for prolonged E/M services. Add-on code +99417 was created by CPT and 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 was established by CMS and 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, it’s important to verify payer policies on which code to use. Remember that these prolonged services include non-face-to-face time spent before or after the direct patient care if those times can be directly attributed to the patient encounter. This is one reason why I expect the OIG to be taking a close look at utilization of these two codes going forward, when providers can count such activities as “time spent documenting in the EHR” after the patient is gone, towards the E/M service’s total time.
- +99415 and +99416. Introduced in 2016, these codes are used with office/outpatient E/M codes but are not limited to the level 5 codes only. There were revised in 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 the time in direct patient contact under physician supervision.
- 99354 and +99355. Prior to 2021, these codes were used in conjunction with office/outpatient E/M codes when prolonged time thresholds were met. After 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. 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 revised in 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 patient’s bedside as well as on the patient’s 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). Note that the time spent on the date of service does not have to be continuous.
- 99358 and +99359. These 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. 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 provider’s time spent on the date of service, time before and after direct patient contact can be included.
Prolonged services have been an audit target for years, and Medicare and commercial payers have struggled to balance the need to reimburse encounters that take much longer than usual with the need to prevent fraud and abuse. Given the recent changes in 2021 to the office/outpatient E/M codes and their accompanying prolonged service codes, it’s a sure bet that payers will be scrutinizing utilization for any increases and conducting audits to ensure compliance with guidelines. Physicians looking to ensure that they are being properly reimbursed often ask me about prolonged services in case they are leaving “money on the table,” and it’s more important than ever to make sure that auditors have the answers ready.