General Surgery Coding Alert

E/M:

Here’s Why the Payer Impacts Your Prolonged Service Coding

Published on Thu May 20, 2021

Only outpatient codes take G2212 or +99217.

Depending on your payer(s) for outpatient evaluation and management (E/M) prolonged service claims, you may have been battling the discrepancies between two codes since Jan. 1.

If you still have uncertainties, we have the answers to several frequently asked questions (FAQs) that can help you out.

Know the Roots of the Problem

CPT^® 2021 introduced +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)).

But concerns that Centers for Medicare and Medicaid Services (CMS) had about the wording within the code descriptor prompted the agency “to create their own, redefined version of +99417 in the form of a HCPCS Level II code,” says Judy Smith, CPC, CPB, CPMA, CEDC, CPC-I, medical coding instructor at Fort Myers Technical College, in Fort Myers, FL.

That code is 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)).

Both codes will help practitioners who spend more time with their patients. For instance, “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, NJ

Distinguish Codes With These FAQs

Here are some questions and answers that should steer you in the right direction for filing claims using +99217 or G2212.

FAQ 1: Does the payer impact whether you use +99217 or G2212 to report prolonged services?

Answer 1: Yes. Medicare will not accept +99217. Introducing G2212 for these services allows you to bill prolonged services for Medicare beneficiaries. Commercial payers will probably accept +99217, but you should check with individual payers.

FAQ 2: Are the prolonged service codes +99417 and G2212 limited for use with certain types of services?

Answer 2: Yes. Use these codes only when you’re billing an office or outpatient E/M service based on time using one of these two codes:

99205 (Office or other outpatient visit for the evaluation and management of a new patient … 60-74 minutes of total time is spent on the date of the encounter)
99215 (Office or other outpatient visit for the evaluation and management of an established patient … 40-54 minutes of total time is spent on the date of the encounter).

Don’t use +99417 or G2212 with 99205 or 99215 if you base the E/M level on medical decision making (MDM) instead of time.

Add-on: Both codes include the descriptor “List separately in addition to … codes 99205, 99215.” You won’t see + with both codes, but you should not report either +99417 or G2212 as a stand-alone code. Report either code only in addition to a 99205 or 99215 claim.

FAQ 3: What time limit must the E/M visit exceed for me to use +99417 or G2212?

Answer 3: The answer to that question highlights the primary difference between +99417 and G2212.

CPT^_® instruction illustrates that when a 99205 or 99215 visit hits fifteen minutes beyond the minimum time for the code, you may add code +99417. That’s 75 minutes total time for 99205 and 55 minutes total time for 99215.

By contrast, CMS stated in the 2021 Medicare Physician Fee Schedule Final Rule that you can add G2212 when the time for a 99205 or 99215 visit hits 15 minutes beyond the maximum time for the code. That’s 89 minutes total time for 99205, and 69 minutes total time for 99215.

Example: Your surgeon sees a new patient and reports the E/M service based on time, documenting 78 minutes for the encounter. For Medicare, you would report 99205. For a commercial payer, you may report 99205 and +99417.

FAQ 4: Are +99417 or G2212 limited to full 15 minute increments, or can you bill another unit of the codes for part of a 15-minute interval?

Answer 4: You should not report either +99417 or G2212 for a time interval less than 15 minutes.

Also recall that both codes are for “each” 15 minute increment. That means you can report an additional unit of +99417 or G2212 for each additional 15 minutes (two units at 30 minutes, three units at 45 minutes, etc.)

Caveat: Although both +99417 and G2212 represent a 15 minute interval, recall from FAQ 3 that the starting time for the interval is different. That means the number of units of each prolonged service code could be different for the same total time.

For example: Your surgeon sees an established patient and reports the E/M service based on time, documenting 78 minutes for the encounter. For Medicare, you would report 99215 plus one unit of G2212. For a commercial payer, you may report 99215 and two units of +99417.

FAQ 5: Does the time have to be face-to-face to count toward the prolonged service?

Answer 5: No. Under the new rules allowing you to code office E/M services based on time, you can count the total time spent by the provider on the day of the visit. That includes all work related to the encounter, even non-face-to-face work, such as telephone calls, chart review, etc.

The prolonged service codes +99417 and G2212 encompass an extension of that total time, so it doesn’t all have to be face-to-face.