Ophthalmology and Optometry Coding Alert

When 2021 arrived, so did several coding changes. You are likely still acclimating, in fact. How are you feeling about prolonged service codes? If you could use a refresher course, then keep reading.

Recognize the Codes

The American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) have their own prolonged service codes, each with unique guidelines. Here are their respective codes:

• +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))
• 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) (do not report G2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416). (Do not report G2212 for any time unit less than 15 minutes))

Understand the Agreement on How to Calculate Total Time

CPT^® and CMS agree that time-based code selection includes all the physician time dedicated to the patient on the day of the exam. “This includes face-to-face time and non-face-to-face time,” says Mary Pat Johnson, COMT, CPC, COE CPMA, senior consultant with Corcoran Consulting Group.

“It is limited, however, to time spent on activities or tasks that require the physician or other qualified healthcare professional’s (QHP) expertise.” This could mean recording notes, ordering and reviewing results, and communicating with caregivers. When reporting +99417, keep in mind that general patient education does not count toward time. Only education that directly addresses the condition and treatment for which the patient originally presented counts toward total time.

Use the add-on codes when reporting level five evaluation and management (E/M) codes, 99205/99215 (Office or other outpatient visit…), but only if time rather than medical decision making (MDM) was the basis for selection.

Understand the Disagreement on How to Calculate Additional Time

This is where things get … different. While both prolonged service codes are used in full 15-minute increments, CPT^® code +99417 can be added to 99205/99215 once the encounter extends 15 minutes beyond the low end of time for those codes.

“A peculiar requirement since it means you could report 99215 plus +99417 after 55 minutes of service,” said Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a former CPT^® Editorial Panel member in Pasadena, California. CMS wasn’t on board with this, which prompted the agency to issue G2212, which “cannot be reported until a total of 74+15=89 minutes for 99205 or 54+15+69 minutes for 99215 has been met,” Littenberg continued.

CPT^®: Consider the level-five E/M codes in terms of time: 99205 (…new patient… 60-74 minutes…) and 99215 (… existing patient… 40-54 minutes…). Adding code +99417 represents 1-14 minutes of prolonged service, which means for each additional 1-14 minutes, you add another unit.

CMS: For Medicare patients, you start using G2212 at the 89-minute mark when reporting 99205 and at the 69-minute mark for 99215. This difference is because CMS mandates that prolonged service starts after the practitioner has already provided 15 minutes of care beyond what’s described in 99205 and 99215.

Essentially, CPT^® speaks in terms of services beyond the minimum required time of the primary procedure, whereas CMS speaks in terms of services beyond the maximum required time of the procedure. “The difference between how CPT^® and CMS treat prolonged services comes down to a single word,” says Kelly Shew, RHIA, CPC, CPCO, CDEO, CPB, CPMA, CPPM, CRC, Documentation & Coding Education, Olympia Medical in Livonia, MI. “The distinction between how the two prolonged service codes are applied means the coder must keep the patient’s insurance in mind when assigning the codes.”

Note: Check with the patient’s payer to be sure which set of guidelines they follow.

Remember Some Previous Prolonged Service Codes Are Still Active

It’s important to note that you can still use 99358 (Prolonged evaluation and management service…) and +99359 (Prolonged evaluation and management… each additional 30 minutes (List separately in addition to code for prolonged service)) to report non-face-to-face time. However, they’re only to be used if the care was provided on a different date of service. Also keep in mind that you can report +99354 (Prolonged service(s) in the outpatient setting…) and +99355 (Prolonged service(s)… additional 30 minutes…), but not when you’re also reporting codes 99202-99215. “They are used in conjunction with some psychotherapy visits, outpatient consultations, domiciliary and rest home visits, home visits, and care planning,” says Shew.

Note: When coding +99354 and +99355, CMS requires you document start and stop times.

Look for Specific Times Noted in the Patient Record

“In order to capture prolonged services, providers must document a specific time spent with or on the patient for that date of service. A time range is not acceptable,” explains Shew. The provider can make a statement that incorporates the total time for a day in one location but should also consider making specific notes about how long the face-to-face time was, then add a note later to report additional non-face-to-face time spent. Query the provider whenever you have any questions about the documentation.

The doctor may also want to note how the time was spent, Johnson adds. “Something like ‘75 minutes were dedicated to this encounter, including reviewing incoming records, obtaining detailed history and exam, ordering labs, and speaking with the patient’s primary care or previous ophthalmologist,’” she says.