prolonged cpt code

[jbhuju]

hello

just want to make sure if any of you are billing prolonged code 99417/ G2212. if yes are you getting payment?

thank you

 

[amullen513]

No. I keep getting denials stating that they're not valid codes. Anyone else?

 

[jkyles]

Hi there,
What are you reporting the codes with and what are your denials?

 

[ellistneal]

Hi I know this post is old but our office had a problem with this too. Our physician will report this code with an office visit of level 3-5. The insurance denied the prolonged code. How should this be used?

 

[sls314]

Hi I know this post is old but our office had a problem with this too. Our physician will report this code with an office visit of level 3-5. The insurance denied the prolonged code. How should this be used?

You shouldn't be using it with levels 3 and 4. It can only be added to a Level 5 visit.

If you're coding by time, it's not possible to have a "prolonged service" for a level 3. Going over the time for level 3 would bump up the E/M up to a higher level instead of adding a prolonged service code.

FWIW, I bill prolonged services regularly. New patient consults in radiation oncology frequently take well over an hour, even up to 90 minutes at times. Patients and families have a lot of questions, understandably.

I do get paid for Level 5 visits + 99417/G2212. Sometimes the payer wants to see the note to justify that the time is appropriately documented on the claim, but they do eventually pay when it is appropriately documented.

 

[jkyles]

Hi I know this post is old but our office had a problem with this too. Our physician will report this code with an office visit of level 3-5. The insurance denied the prolonged code. How should this be used?

Hi there,
As noted above, a prolonged service for an office visit is an option when the primary service reaches the time requirement for a level five visit. The primary E/M visit must be coded based on time. If your providers want to report prolonged services they must document time spent on the activities listed in the 2023 CPT manual. If they want to stick with MDM and not document time then prolonged services won't be an option.

To report a prolonged service the total time must meet the threshold for 99417 (2023 CPT Manual) or G2212 (Medicare rules). Some private payers follow Medicare rules so read each plan's reimbursement policy carefully to prevent improper payments.

 

[julieordway]

Hi there,
As noted above, a prolonged service for an office visit is an option when the primary service reaches the time requirement for a level five visit. The primary E/M visit must be coded based on time. If your providers want to report prolonged services they must document time spent on the activities listed in the 2023 CPT manual. If they want to stick with MDM and not document time then prolonged services won't be an option.

To report a prolonged service the total time must meet the threshold for 99417 (2023 CPT Manual) or G2212 (Medicare rules). Some private payers follow Medicare rules so read each plan's reimbursement policy carefully to prevent improper payments.

Quick question--We rarely bill for prolonged services but had one come up just today. Provider documents the following:
"Time spent today in preparing for the visit, face-to-face during the visit, in discussion with family and documentation after the visit was in excess of 60 minutes"
Is correct coding 99215, 99417? Payer is a Medicare Advantage plan.
Thank you!

 

[rachaelwilleford]

Quick question--We rarely bill for prolonged services but had one come up just today. Provider documents the following:
"Time spent today in preparing for the visit, face-to-face during the visit, in discussion with family and documentation after the visit was in excess of 60 minutes"
Is correct coding 99215, 99417? Payer is a Medicare Advantage plan.
Thank you!

Nope, they need to be documenting actual total time, not just "in excess of". Also 60 minutes won't cut it for Medicare with the way they apply the prolonged service time. Most Medicare Advantage plans use the G codes for prolonged services. It's payer choice as to which set of codes they take on this.

Try this: https://practice.asco.org/sites/default/files/drupalfiles/2021-01/New-Prolonged-Jan-2021.pdf

 

[jkyles]

Quick question--We rarely bill for prolonged services but had one come up just today. Provider documents the following:
"Time spent today in preparing for the visit, face-to-face during the visit, in discussion with family and documentation after the visit was in excess of 60 minutes"
Is correct coding 99215, 99417? Payer is a Medicare Advantage plan.
Thank you!

Hi there,

• For time-based E/M coding the provider must document the exact time.
• Medicare uses a separate set of G codes for prolonged services that have different time requirements.
• The rules and time thresholds for various prolonged services (and the appropriate G codes) are located here: https://www.cms.gov/files/document/r11842cp.pdf

Also be aware that some private payers also follow Medicare's rules (it saves them money.)

 

[julieordway]

Hi there,

• For time-based E/M coding the provider must document the exact time.
• Medicare uses a separate set of G codes for prolonged services that have different time requirements.
• The rules and time thresholds for various prolonged services (and the appropriate G codes) are located here: https://www.cms.gov/files/document/r11842cp.pdf

Also be aware that some private payers also follow Medicare's rules (it saves them money.)

Thanks for the input. For clarification, the documentation supports a 99215, but if the required extra time frame were to be met for prolonged services (55-69 minutes for established-commercial/99417; OR 69-83 for Medicare/G2212), it needs to state "TOTAL time"?

 

[leastratton1001]

Hi there,

• For time-based E/M coding the provider must document the exact time.
• Medicare uses a separate set of G codes for prolonged services that have different time requirements.
• The rules and time thresholds for various prolonged services (and the appropriate G codes) are located here: https://www.cms.gov/files/document/r11842cp.pdf

Also be aware that some private payers also follow Medicare's rules (it saves them money.)

So am I reading this accurately. For example Medicare threshold for G0318 is 110 minutes for home/residence visit for new patient. So in order to include G0318 with 99350 the visit would need to be at least 110 minutes long rather than the 75 minutes established by the CPT guidelines?

 

[jkyles]

So am I reading this accurately. For example Medicare threshold for G0318 is 110 minutes for home/residence visit for new patient. So in order to include G0318 with 99350 the visit would need to be at least 110 minutes long rather than the 75 minutes established by the CPT guidelines?

Right. Medicare does not use the the CPT time thresholds, which is why it created new codes.
HOWEVER, for home visits Medicare does allow providers to count time before and after the date of the encounter. They just have to remember to document it and the coder has to remember to check.

 

[jkyles]

Thanks for the input. For clarification, the documentation supports a 99215, but if the required extra time frame were to be met for prolonged services (55-69 minutes for established-commercial/99417; OR 69-83 for Medicare/G2212), it needs to state "TOTAL time"?

Hi,
The visit can't coded based on time at all because the provider didn't document exactly how much time they spent, they gave an estimate. The underlined part is the problem.

"Time spent today in preparing for the visit, face-to-face during the visit, in discussion with family and documentation after the visit was in excess of 60 minutes"

It should be something like "61 minutes" or "73 minutes" or however much time they actually spent, in minutes. They don't need to document the words "total time" but it wouldn't certainly wouldn't hurt.

Because the visit can't be coded based on time, a prolonged service code isn't an option.

Bottom line, your provider needs to document the exact time so you can give them full credit for their work.

 

[leastratton1001]

Right. Medicare does not use the the CPT time thresholds, which is why it created new codes.
HOWEVER, for home visits Medicare does allow providers to count time before and after the date of the encounter. They just have to remember to document it and the coder has to remember to check.

Out of curiosity- as I am learning this we are struggling with the time stamp piece in EMRs - for example the clinician didn’t finish their documentation timely or went back and added more the next day- I’m very curious how others utilize those EMR time stamps for determining the time or if you generally look for the clinician to indicate in their actual documentation the time spent with the patient.

 

[sls314]

Out of curiosity- as I am learning this we are struggling with the time stamp piece in EMRs - for example the clinician didn’t finish their documentation timely or went back and added more the next day- I’m very curious how others utilize those EMR time stamps for determining the time or if you generally look for the clinician to indicate in their actual documentation the time spent with the patient.

The coder should not be using the EMR time stamps to calculate time for the purpose of leveling the E/M visit.

The provider has to document the time.

 

[jkyles]

Out of curiosity- as I am learning this we are struggling with the time stamp piece in EMRs - for example the clinician didn’t finish their documentation timely or went back and added more the next day- I’m very curious how others utilize those EMR time stamps for determining the time or if you generally look for the clinician to indicate in their actual documentation the time spent with the patient.

Hi there, as sls noted above, the provider must document their time.

If you use time stamps you might capture time that the provider had the note open but wasn't performing tasks related to that patient's visit, or miss time for work that they performed while the note was closed. The time stamp can be helpful in making sure you don't count work before or after the allowed encounter period.