EM Coding Alert

Learn the difference between +99417 and G2212.

If you thought getting reimbursed for prolonged services was hard before this year, you should know it just got a whole lot harder now that the Centers for Medicare & Medicaid Services (CMS) has introduced G2212 (Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services)…).

That’s because you now have to decide when and how to use G2212 or its CPT^® 2021 counterpart +99417 (Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes of total time (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)).

To end the confusion, we’ve broken down the time components for both codes to help you use them accurately every time. But first, a little history.

The Winding Road to G2212

The code began life in CMS’ 2020 proposed rule as a mysterious placeholder code, 99XXX, and eventually morphed into +99417 following the release of CPT^® 2021.

But that was just the beginning of the confusion. CMS made clear in the 2021 Medicare Physician Fee Schedule (MPFS) final rule that code +99417 didn’t satisfactorily convey how to accurately report prolonged services following an office or other outpatient visit. “In the past, getting reimbursed for prolonged office or other outpatient E/M services was difficult,” recounts Judy Smith, CPC, CPB, CPMA, CEDC, CPC-I, medical coding instructor at Fort Myers Technical College, in Fort Myers, Florida. “While that’s no longer the case with +99417, the concerns about the wording within the code description prompted CMS to create their own redefined version of +99417 in the form of a HCPCS Level II code,” Smith explains.

That’s the basis behind CMS’ introduction of code G2212 in the final rule. “You’ll find code G2212 is useful for reporting medically necessary extended high-level care to patients that may include certain education and counseling services,” says John Piaskowski, CPC, CUC, CPMA, CCC, CCVTC, CIRCC, CGSC, CGIC, COSC, CRC, Compliance Coder at Shore Physicians Group in Somers Point, New Jersey.

Consider Their Justification for the Change

Basically, CMS wasn’t satisfied with the portion, stating “requiring total time with or without direct patient contact beyond the usual service.” CMS explains in the final rule that “the term ‘total time’ is unclear because office/outpatient E/M visits now represent a range of time, and ‘total’ time could be interpreted as including prolonged time.” CMS adds that the term “usual service” doesn’t include a concrete definition. This adds to the confusion since there’s no point of reference for when a practitioner exceeds their “usual” allotted time (previously indicated as the total time estimate in the code description).

But CMS’ underlying concern lies with the potential for coders to fundamentally misinterpret the +99417 code description so that it results in billing +99417 when the total time criteria has not been met.

CMS explains that while the wording of the +99417 code description seemingly might leave it open to interpretation, they believe +99417 is meant to be reported for services that extend 15 minutes or beyond the maximum total time range for codes 99205 (Office or other outpatient visit for the evaluation and management of a new patient …) and 99215 (Office or other outpatient visit for the evaluation and management of an established patient …). For instance, consider the time range included in each respective code description:

• 99205: 60-74 minutes
• 99215: 40-54 minutes

CMS’ concern is that coders may consider any service ending within the aforementioned time ranges to be equally eligible for +99417 consideration. For instance, if a coder is working on a chart in which an established patient visit ends at 46 minutes, the +99417 description leaves open the possibility to simply add the 15 or more minutes beyond where the “usual service” ended at 46 minutes. So, if the coder documents that the provider spent 15 additional minutes of indirect patient contact, the total time spent would only equate to 61 minutes. However, according to CMS, in order to report a prolonged services code, the coder must have documentation of a minimum of 69 minutes. That means, in our example, the coder would be double counting for a service that’s fully encompassed by 99215 according to CMS.

Ultimately, the underlying concern for +99417 to be misused and misreported led to CMS’ response in creating code G2212. As you can see in the G2212 code description, CMS leaves nothing open to interpretation by revising the description to state “beyond the maximum required time of the primary procedure which has been selected using total time.”

Add in a Few More Essential Details

For Medicare patients, you should exclusively report G2212 for eligible E/M services that meet the required criteria. You should check with other payers for policies on G2212 and +99417 reimbursement. Keep in mind that some commercial payers will not reimburse for prolonged services in any capacity. The Medicare unadjusted fee schedule for G2212 is $31.44 for services that reach 15-29 minutes beyond 99205 and $30.14 for services over 15-29 minutes beyond 99215.

Furthermore, take note that +99417 and G2212 apply to E/M services and procedures performed in an office or other outpatient setting. The code description includes the term “procedure,” but you may code prolonged services with both in-office procedures and/or other office/outpatient E/M services. However, codes +99417 and G2212 may not be billed with any E/M codes other than 99205 and 99215.

Lastly, note that G2212 and +99417 have been permanently added the Medicare telehealth services list.