Wiki Prolonged code 99417 denials as included

[Faith07]

Hi All,

We are receiving denials for CPT add on 99417 indicating included. We are billing a level 5 E/M w modifier -25 and a 99417 (no mod) with separate procedures on the same day. We are experiencing 99417 denials as included while the E/M (99215 -25 or 99205 -25) and the procedure are being paid (all codes meet time requirements and documentation).

Codify indicates -25 is eligible on 99417 however all other guidance is indicating it should not need a modifier 25 on the 99417 due to it being an add on code for 99215/99205 and that has the modifier 25. Has anyone run into this?

 

[Pam Warren]

If the procedure is a minor procedure, they may be bundling the prolonged service if your documentation doesn't specifically state that the prolonged service time is separate from the procedure.

 

[Coder2hear813]

In my experience, many of the major payers (BCBS, Humana, Medicare, United Healthcare) do not accept CPT 99417 for prolonged services. Instead, they adopted the Medicare prolonged service code, CPT G2212. The time thresholds for reporting these codes are very different.

 

[Faith07]

Thank you, We use G2212 for UHC but BCBS we still use 99417. We have the time thresholds for both 99417 and G2212 but it doesn't seem like it's this issue. We have seen others advise to also add a mod also to 99417 if 99215/99205 has it.