Otolaryngology Coding Alert

As you’ll see, the underlying purpose for these codes is the same, but CMS felt the need to include their own version of +99417 that elaborates on a few points that lack clarity.

Read on for a breakdown of the need for the change, what it means for your practice, and how to implement it into your day-to-day coding.

Outline This Reason for the Change

CMS outlines in the final rule that the lack of clarity surrounding code +99417 was enough to justify the creation of a brand-new HCPCS Level II code that better conveyed the parameters in which you should report prolonged services following office or other outpatient services. CMS begins by tracing the issue back to the code description within code +99417. “In the past, getting reimbursed for prolonged office or other outpatient E/M services was difficult,” explains 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 have prompted CMS to create their own redefined version of +99417 in the form of a HCPCS Level II code,” Smith adds.

Specifically, 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).

At first, their point might not be easily decipherable without reading it back over a few times. However, the underlying concern lies with the potential for coders to fundamentally misinterpret the code description so that it results in billing for code +99417 when the total time criteria has not been met.

CMS explains that while the wording of the +99417 code description is somewhat vague, they believe that code +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

The concern from CMS 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 description within code +99417 leaves open the possibility for the coder to simply add the 15 or more minutes on from where the “usual service” ended at 46 minutes. So, if the coder documents that the provider partook in 15 additional minutes of indirect patient contact, the total time spent would only equate to 61 minutes. However, in order to report +99417 x 1, the coder must have documentation of a minimum of 69 minutes. In an instance such as this, the coder would be double counting for a service that code 99215 fully encompasses.

Ultimately, the underlying concern for +99417 to be misused and misreported lead to CMS’ response in creating code G2212. As you can see in the code description, CMS leaves no room 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.”

Consider a Few Additional Points

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.

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 alongside both in-office procedures and/or other office/ outpatient E/M services. However, codes +99417 and G2212 may not be billed alongside any other E/M codes beyond 99205 and 99215.

Lastly, keep in mind that G2212 and +99417 have been added as permanent additions the Medicare telehealth services list.