Orthopedic Coding Alert

Question: Our provider performed an office evaluation and management (E/M) service over the phone that lasted 55 minutes. Can we bill +99354 in addition to 99443?

Montana Subscriber

Answer: The answer may depend on the payer. You are correct that the appropriate code for the phone E/M service is 99443 (Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion).

Although The Centers for Medicare & Medicaid Services (CMS) provides a different prolonged service code for 2021 (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…), it only applies to codes 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.).

Because your case doesn’t match the G2212 criteria, you may turn to +99354 (Prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service; first hour (List separately in addition to code for outpatient Evaluation and Management …) with the phone E/M codes. You should contact your payer for clarification.