December 25, 2020 | By By Grant Huang, CPC, CPMA
The New Year is nearly upon us and with it, implementation of the much-talked-about 2021 E/M guidelines for office/outpatient codes 99202-99215. These guidelines include completely revamping how time works for selecting code levels, which in turn has resulted in brand new rules for prolonged services.
In this article, we will examine how prolonged services are changing, including an important distinction between CPT and CMS rules.
Combining face-to-face and non-face-to-face time
First and foremost, for codes 99202-99215, you can combine face-to-face and non-face-to-face time, and the time spent can be non-consecutive, so long as they all occur on the date of the E/M encounter. Only the billing provider’s time may be counted. Secondly, as the guidelines state, “time may be used to select a code level in office or other outpatient services whether or not counseling and/or coordination of care dominates the service.”
The latter point means that providers no longer have to insert a statement to the effect of “more than 50% of the time was spent on counseling/coordination of care.” Instead, CPT provides a list of activities that are covered under the new, combined time for 99202-99215:
- preparing to see the patient (e.g., review of tests)
- obtaining and/or reviewing 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 record
- independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
It will still be important for the provider to document which of these activities the time was spent on for any given patient, but this is a much broader menu of activities that can be included – just imagine being able to count time spent “documenting clinical information” into an EHR note!
Two new codes for prolonged services
As a result of this new definition of time, the existing prolonged services codes +99354 and +99355 for prolonged services with direct patient contact can no longer be reported with 99202-99215. Instead, there are two new codes being created: +99417 and +G2212.
Both of these codes represent combined face-to-face and non-face-to-face time, and are used as follows:
- They are add-on codes that can only be used with parent codes 99205 and 99215. You cannot add “prolonged” time to codes lower than level 5, because you would bill a higher level of service, up to the level 5 code.
- Once the time requirement for a level 5 code (99205 or 99215) has been met and exceeded by at least 15 minutes, you may bill one unit of +99417 or +G2212.
- Crucially, CPT uses the minimum required time for 99205/99215 as a starting point for counting units of +99417, while CMS uses the maximum required time for 99205/99215 as a starting point for counting units of +G2212.
CPT minimum time for +99417
In 2021, for 99205, CPT specifies a time requirement of 60-74 minutes for 99205, and 40-54 minutes from 99215. This is a slight departure from how E/M times were presented in 2020 and previous years, where a single “typical” time was given, e.g. 40 minutes for 99215.
Thus the minimum time required for 99205 is 60 minutes and the minimum time required for 99215 is 40 minutes. The CPT descriptor for +99417 states than this one unit of this code becomes billable if an additional 15 minutes were spent beyond the minimum time for 99205 and 99215. Thus for 99205, at 75 minutes of time, +99417×1 can be reported in addition to 99205 itself. Likewise, for 99215, at 55 minutes, +99417×1 can be reported in addition to 99215 itself.
CMS rules and +G2212
It’s important to note that Medicare will use CPT 2021 times for selecting E/M codes. A CMS official, Christiane LaBonte, stated in a Dec. 9, 2020 open door call that practitioners will use CPT 2021 times when selecting codes 99202-99215 based on time. Her statement clarifies language in Medicare’s 2021 Physician Fee Schedule (PFS) Final Rule that seemed to suggest a different set of times that were significantly longer for each code; those times were used purely for rate-setting and have no bearing on actual coding, LaBonte said.
With that out of the way, +G2212 was created by CMS because the agency believes it is more appropriate to base the start of prolonged service time on the maximum time requirement for the parent code. In the 2021 PFS Final Rule, CMS explains why it decided to create its own HCPCS code, +G2212: “While we prefer to align with CPT coding to reduce potential confusion to practitioners, we continue to believe that CPT code 99417 as written is unclear and that allowing reporting of CPT code 99417 when the minimum required time for the level 5 visit is exceeded by at least 15 minutes would result in double counting time.”
This is why CMS uses the maximum time; for 99205 this is 74 minutes for 99215 this is 54 minutes. So one unit of +G2212 becomes billable if an additional 15 minutes is spent beyond 74 minutes (99205) or 54 minutes (99215). Thus for 99205, when Medicare is the payer, at 89 minutes, +G2212x1 is billable in addition to 99205 itself. For 99215, when Medicare is the payer, at 69 minutes, +G2212x1 is billable in addition to 99215 itself.
You may be anxious at this point to see the official sources. CMS released Transmittal 10505 on Dec. 4, 2020, explaining precisely how +G2212 works, including a table of examples. For CPT’s explanation of how +99417 works, including detailed examples, please refer to page 43 of the AMA’s 2021 CPT Manual.