Cardiology Coding Alert

Focus on new CMS prolonged service G codes.

No matter your specialty, understanding how to correctly bill evaluation and management (E/M) can mean the difference between getting a denial or not. Knowing how different payers expect these E/M services to be paid is as equally important.

Context: The Centers for Medicare & Medicaid Services (CMS) sometimes dictates coding or billing standards or interpretations for providers who see Medicare beneficiaries. Sometimes other payers adopt these rules.

Take a look at this info from CMS so you can keep your patients’ medical records in good order.

Editor’s note: CMS unveiled an updated version of its Medicare Learning Network (MLN) Evaluation and Management Services Guide in August 2023, after it was previously withdrawn in February 2023.

Note These Differences in Critical Care Prolonged Services

The current MLN E/M guide highlights a major disagreement between CMS and CPT^® over when you can apply +99292 (… each additional 30 minutes (List separately in addition to code for primary service)) to 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) to reflect prolonged critical care services.

CMS tells you to ignore CPT^® instructions to apply +99292 once the provider has met 75 minutes of critical care service time. Instead, the MLN E/M guide instructs that you only apply +99292 when the provider spends 104 minutes (74 + 30 = 104 minutes) or more with the patient.

“This contradicts the AMA’s long-standing rationale for the initial critical care time requirement (99291) and when to apply the additional time code (+99292) threshold,” notes Kelly Loya, CPC, CHC, CPhT, CRMA, CHIAP, associate partner at Pinnacle Enterprise Risk Consulting Services. In the Time section of the CPT^® code book, the AMA states, “A unit of time is attained when the mid-point is passed. For example, an hour is attained when 31 minutes have elapsed (more than midway between zero and 60 minutes).” So, “CPT^® defined the codes originally to require 99291 to report the first hour and +99292 for each additional 30 minutes. That means two units of +99292 require 134 minutes, 3 units require 164 minutes, and so on,” explains Loya.

However, the MLN E/M guide states “the general CPT^® rule about the midpoint for certain timed services doesn’t apply.” In other words, “CMS is requiring providers to meet the full 30 minutes beyond the definition’s maximum time of 74 minutes, plus the full 30 minutes for +99292 (or a total of 104 minutes) to report +99292 with 99291,” Loya adds.

Coding tip: Watch commercial payer policies to see if they follow CPT^® or CMS guidance.

Explore New CMS Prolonged Service G Codes

At the beginning of 2023, CMS introduced three new prolonged E/M service codes for use with inpatient, observation, nursing facility, home or resident visits, and for cognitive impairment assessment and care planning services. The codes in question are:

• G0316 (Prolonged hospital inpatient or observation care evaluation and management service(s) …)
• G0317 (Prolonged nursing facility evaluation and management service(s) …)
• G0318 (Prolonged home or residence evaluation and management service(s) …)

The MLN E/M instructions provide clear standards for time thresholds and how to count time for each one. For example, you would report one unit of G0316 for any Medicare patient inpatient/observation visit coded with 99223 (Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded.) when the provider’s visit meets the 90-minute time threshold since the visit has met the full 15 minutes for G0316.

CPT^® and CMS follow the same threshold for reporting prolonged time with 99223 and 99233 (Subsequent hospital inpatient or observation care, per day …), as the codes include a “must be met or exceeded time” versus a time range (so there is no difference in time threshold calculation based on minimum versus maximum), and time spent can only be counted on the date of service. For non-Medicare patients, the correct code would be +99418 (Prolonged inpatient or observation evaluation and management service(s) time ... each 15 minutes of total time ...).

However, for reporting prolonged time with 99236 (Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date … When using total time on the date of the encounter for code selection, 85 minutes must be met or exceeded.), CMS uses pre- and/or post-visit times on other dates for certain services. That gives a total time of 94 minutes for 99236, which is rounded to the nearest five minutes (95 minutes). You would report a single unit of G0316 once 15 minutes beyond this time has been reached (110 minutes).