Make Quick Work of Prolonged Care Coding
Key changes in the 2023 MPFS final rule provide coding clarity.
Prolonged services are provided when the time spent caring for a patient exceeds the usual evaluation and management (E/M) service. Coding these services has changed considerably since the American Medical Association (AMA) revised its E/M guidelines in 2021 and 2023. Read on to learn about the latest updates, additions, and deletions to the guidelines to make sure you are coding prolonged services correctly for claims with dates of service (DOS) on or after Jan. 1, 2023.
Total Time Counts
The 2023 E/M guidelines clarify that, for coding purposes, time for prolonged services is the total time on the date of the encounter. The guidelines for selecting level of service based on time say:
It includes both the face-to-face time with the patient and/or family/caregiver and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff). It includes time regardless of the location of the physician or other qualified health care professional (eg, whether on or off the inpatient unit or in or out of the outpatient office). It does not include any time spent in the performance of other separately reported service(s).
The guidelines go on to list several activities that count toward total time when performed on the same date of the encounter:
- 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 healthcare professionals (when not separately reported)
- Documenting clinical information in the electronic or other health record
- Independently interpreting results (when not reported separately) and communicating results to the patient/family/caregiver
- Care coordination (not separately reported)
To support billing based on time, the total time on the DOS spent performing these activities should be documented in the clinical note.
New and Expanded Codes
CPT® code 99417 was created in 2021 to report prolonged E/M services performed in the outpatient setting in conjunction with level 5 office or other outpatient E/M visits only (99205 or 99215). In 2023, the description of CPT® 99417 was expanded to include other outpatient E/M services beyond office visits and now may be used with outpatient consultations (99245), home or residence visits (99345, 99350), and cognitive assessment and care planning (99483).
99417 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)
CPT® code 99418 was added this year for prolonged E/M services provided in the inpatient or observation setting.
99418 Prolonged inpatient or observation 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)
Report 99418, as appropriate, in conjunction with initial inpatient or observation care (99223), subsequent inpatient or observation care (99233), hospital inpatient or observation care including same day admission and discharge (99236), inpatient or observation consultations (99255), initial nursing facility care (99306), and subsequent nursing facility care (99310).
The 15-minute time requirement established in 2021 for the highest level service and 15-minute incremental reporting time apply to both 99417 and 99418 for all applicable E/M services. A full 15-minute increment must be reached; the mid-point rule does not apply to prolonged services.
Four previous prolonged care codes were deleted in 2023: 99354, 99355, 99356, and 99357. Parentheticals for 99354 and 99355 direct coders to 99417, and parentheticals for 99356 and 99357 direct coders to 99418.
CPT® codes 99358 and 99359 for reporting prolonged services occurring on a date other than the face-to-face E/M are unchanged, but there are new reporting guidelines that clarify:
- These codes may be used regardless of whether time or medical decision making (MDM) was or will be used to select the level of the face-to-face E/M service.
- These codes may only be reported once per date, and that date must be different than the date for the face-to-face service.
- The non-face-to-face prolonged service and the face-to-face E/M service must be related.
As before, a prolonged service lasting less than 30 minutes is not reported separately. So, even though the descriptor for 99358 says “first hour,” the provider must spend 30-60 minutes conducting a prolonged service to bill 99358, and an additional 30 minutes must be spent before billing add-on code +99359.
CPT® codes 99415 and 99416 report prolonged clinical staff time in the office or outpatient setting in conjunction with an outpatient E/M (99202-99215) — this is unchanged. However, new reporting guidelines clarify their use:
- Code these services based on the total face-to-face time that clinical staff spends with the patient/family/caregiver; the time does not have to be continuous (see Table 1).
- Non-face-to-face time is not counted.
- These codes may not be billed on the same DOS as 99417.
Final Rule for Medicare
The 2023 Medicare Physician Fee Schedule (MPFS) final rule made similar changes to prolonged services coding in response to the addition of 99418 as it did in response to 99417 in 2021.
In 2021, the Centers for Medicare & Medicaid Services (CMS) created HCPCS Level II code G2212 for prolonged office or other outpatient E/M services provided to Medicare beneficiaries. Note that G2212 has different reporting time requirements than 99417. CMS also approved G2212 to be coded with cognitive assessment and care planning (99483) in lieu of 99417.
CMS also created three new HCPCS Level II codes — G0316, G0317, and G0318 — to be reported in place of 99418 for prolonged hospital inpatient or observation care E/M services:
- G0316 may be reported in addition to 99223, 99233, and 99236 for inpatient and observation visits. Similar to 99418, the total time spent in applicable activities on the DOS for 99223 and 99233 may be counted. CMS expanded the time frame for same day admit/discharge (99236) to include time spent in applicable activities on the DOS and up to three days after.
- G0317 may be reported in addition to 99306 and 99310 for nursing facility E/M services. CMS expanded the time frame to count time spent in applicable activities to include the DOS, one day prior, and up to three days after.
- G0318 may be reported in addition to 99345 and 99350 for home/residence E/M services. CMS expanded the time frame to count time spent in applicable activities to include the DOS, up to three days prior, and up to seven days after.
CMS issued a notice on March 14 correcting the time requirements for initial reporting of G0316 when reported with inpatient and observation services. These changes are retroactive to Jan. 1, 2023. However, as noted in the March AAPC Knowledge Center article, “CMS Corrects Time Thresholds for Prolonged Services,” the time for inpatient/observation same-day admit/discharge services (99236) may still not be correct.
The CPT® descriptor for 99236 states, “When using total time on the date of the encounter for code selection, 85 minutes must be met or exceeded.” Therefore, using the same methodology for the other corrections, the correct time threshold for 99236 would be 100 minutes (15 minutes above 85 minutes), not 110 minutes as CMS published (see Table 2). Although current manual guidance must be followed, it is in the interest of billers and revenue cycle leaders to watch for future revisions and notices.
Although the time frames to count care activities have been expanded for these codes, the threshold to report the codes for nursing home and home/residence services is higher than the threshold to report 99418.
Coders and billers need to be vigilant to identify the patient’s payer, so that all time spent in applicable activities during each time frame is identified and counted accurately. Providers may need additional education to ensure care activities that may be counted between face-to-face visits are documented. Revenue cycle leaders should identify payers who will follow CMS’ lead to avoid unnecessary denials.
Angela Wubben, BS, CPC, CPB, has acted as an AAPC dental SME, auditor, and Billing Advisory Committee member. She also develops educational content and speaks on E/M coding, ICD-10-CM, documentation compliance, modifiers, HIPAA, and OSHA.
Laidy Diana Martinez, CPC, CPB, CGSC, CGIC, CASCC, is an AAPC gastroenterology subject matter expert and AAPC Billing Advisory Committee member. Martinez is also a teaching assistant for AAPC’s Virtual Instructor-Led Training program.
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