Note: For home and residence services and assessment of cognitive functions, see below.
Coding for prolonged services is complicated by the fact CPT ® and CMS use different codes and different time thresholds. These codes and rules have been in effect since 2021.
In their 2021 Physician Fee Schedule Final Rule, CMS indicated its agreement with the new E/M definitions for codes 99202-99215 that were developed by the AMA that are in the 2021 CPT ® book. However, CMS and the AMA are not in agreement about the use of prolonged care code 99417, resulting in HCPCS code G2212.
A practitioner may include these activities in their time, when using time to select an E/M service:
Per CPT, use 99417 for office visits, outpatient consults, home and residence services and cognitive assessment planning.
# ✚ 99417 “Prolonged outpatient evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time (List separately in addition to the code of the outpatient Evaluation and Management service)”
(Use 99417 in conjunction with 99483, when the total time on the date of the encounter exceeds the typical time of 99483 by 15 minutes or more.)
CMS developed its own code G2212
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)).”
| Codes | Time | CPT ® : times to add on 99417 | CMS: times to add on G2212 |
| 99205 | 60 min | 75 | 89 |
| 99215 | 40 min | 55 | 69 |
| Cognitive assessment planning | |||
| CPT 99417 | HCPCS code G2212 | ||
| Add to | Time on date of service | Add to | Notes |
| 99483 | Typical time is 60 minutes; use 99417 for 75 minutes or more | 99483 | Use time three days before visit, date of visit and 7 days after visit |
Both CMS and CPT allow a prolonged service in addition to 99483, assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home. The typical time for this code is 60, making the threshold time to add a prolonged care code 75 minutes. Note that CMS allows the practitioner to include time spent three days before the date of the visit and seven days after.
| Home and residence services | |||
| CPT 99417 | HCPCS code G0318: 15 minutes | ||
| Add to | Time on date of service | Add to | Notes |
| 99345, 99350 | 99345 use 99417 at 90 minutes; 99350 use 99417 at 75 minutes | 99345, 99350 | Use time three days before visit, date of visit and 7 days after visit |
For CPT®, use add-on code 99417 for prolonged care. As with all of these codes, both CPT®️ and HCPCS, the prolonged code may only be added to the highest-level code in the category and then only when time is used to select the service. The definition of 99417 is above.
G0318 (Prolonged home or residence evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using 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 99345, 99350 for home or residence evaluation and management services). (Do not report G0318 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99417). (Do not report G0318 for any time unit less than 15 minutes))
CMS is allowing time on days prior to and after the date of the encounter to be used for prolonged services in relation to home/residence visits.
| Inpatient and observation services | |||
| CPT 99418: 15 minutes | HCPCS code G0316: 15 minutes | ||
| Add to | Time on date of service | Add to | Notes |
| 99223, 99233, 99236, 99255 | 99223 use 99418 at 90 minutes; 99233 use 99418 at 65 minutes; 99236 use 99418 at 100 minutes; 99255 use 99418 at 95 minutes | 99223, 99233, 99236 | 99223, 99233 use time only on date of visit. For 99236, use time on date of visit to three days after. CMS does not recognize consult codes. |
99418 Prolonged inpatient or observation evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time (List separately in addition to the code of the inpatient and observation Evaluation and Management service)
(Use in 99418 conjunction with 99223, 99233, 99236, 99255, 99306, 99310)
(Do not report 99418 on the same date of service as 90833, 90836, 90838, 99358, 99359)
(Do not report 99418 for any time unit less than 15 minutes)
99418 may be used on the highest-level initial and subsequent inpatient and observation codes, inpatient consult, and initial and subsequent nursing facility services. It may not be reported with psychotherapy or non-face to face prolonged care codes, or discharge services 99238, 99239, 99315, 99316. It may not be used with Emergency Department codes. The full 15 minutes is required and time must have been used to select the level of service.
CMS does not recognize CPT® code 99418. For Medicare patients, there is a HCPCS code. CMS is not using the published CPT typical times for the codes, but the time in the CMS time file, developed by the RUC. For Medicare patients, the time thresholds to add G0316 are different than those in our CPT books. CMS is not allowing practices to report G0316 when the time is 15 more minutes than the CPT® typical time. Instead, in a break from prior policy, CMS is using the time in the CMS time file. The 2023 time file is here.
G0316 Prolonged hospital inpatient or observation care evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using 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 99223, 99233, and 99236 for hospital inpatient or observation care evaluation and management services). (Do not report G0316 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99418). (Do not report G0316 for any time unit less than 15 minutes)
See the CMS Table 24 below. CMS is allowing time on after the date of the encounter to be used for prolonged services in relation to hospital services.
Prolonged services in a nursing facility: CPT code 99418/HCPCS code for Medicare G0317
| Nursing facility care | |||
| CPT 99418: 15 minutes | HCPCS code G0317: 15 minutes | ||
| Add to | Time on date of service | Add to | Notes |
| 99306, 99310 | Use with 99306 at 65 minutes; use with 99310 at 60 minutes | 99306, 99310 | Use time one day before visit, date of visit and three days after visit |
CPT ® defines the new prolonged add-on code 99418 (above) as the code to use in a nursing facility, as well as in the hospital. And, CPT®️ simply states to use the code when the total time of the highest-level service (selected based on time) is 15 minutes more than the time described in the CPT®️ book. Both the base time and the prolonged time can include face-to-face care and non-direct care on the date of the visit.
G0317 (Prolonged nursing facility evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using 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 99306, 99310 for nursing facility evaluation and management services). (Do not report G0317 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99418,). (Do not report G0317 for any time unit less than 15 minutes))
| Primary E/M Service | Prolonged Code* | Time Threshold to Report Prolonged | Count physician/NPP time spent within this time period (surveyed timeframe) |
| Initial IP/Obs. Visit (99223) | G0316 | 105 minutes | Date of visit |
| Subsequent IP/Obs. Visit (99233) | G0316 | 80 minutes | Date of visit |
| IP/Obs. Same-Day Admission/Discharge (99236) | G0316 | 125 minutes | Date of visit to 3 days after |
| IP/Obs. Discharge Day Management (99238-9) | n/a | n/a | n/a |
| Emergency Department Visits | n/a | n/a | n/a |
| Initial NF Visit (99306) | G0317 | 95 minutes | 1 day before visit + date of visit +3 days after |
| Subsequent NF Visit (99310) | G0317 | 85 minutes | 1 day before visit + date of visit +3 days after |
| NF Discharge Day Management | n/a | n/a | n/a |
| Home/Residence Visit New Pt (99345) | G0318 | 140 minutes | 3 days before visit + date of visit + 7 days after |
| Home/Residence Visit Estab. Pt (99350) | G0318 | 110 minutes | 3 days before visit + date of visit + 7 days after |
| Cognitive Assessment and Care Planning (99483) | G2212 | 100 minutes | 3 days before visit + date of visit + 7 days after |
| Consults | n/a | n/a | n/a |
* Time must be used to select visit level. Prolonged service time can be reported when furnished on any date within the primary visit’s surveyed timeframe, and includes time with or without direct patient contact by the physician or NPP. Consistent with CPT’s approach, we do not assign a frequency limitation.
The source of this chart is CMS’s 2023 Final Rule. It doesn’t follow CPT typical times, or CPT prolonged services rules. It includes time for some services on the days before or after the face-to-face encounter. It adds to confusion and complexity for medical practices.
It was never easy for clinicians to select prolonged services codes. When they were applicable to all levels of service, the threshold time was different for each code. Now, they are only applicable on the highest level of service, but there are two sets of codes and the time thresholds are different for each one. This makes no sense. Effectively, all prolonged services coding will need to be done by coders. Effectively, it is so byzantine that most practices will never be able to bill for them.
Question:
Can an add-on code be submitted without its primary code? In particular, the add-on prolonged services HCPCS codes developed by CMS.
Answer:
An add-on code must be submitted with its primary code. A colleague said she was getting conflicting opinions about this. Let’s see what CPT® and CMS say.
Page xviii of the CPT® Professional Edition 2024 states, “Add-on codes are always performed in addition to the primary service or procedure and must never be reported as a standalone code.” It is easy to ignore the information in the introduction of the CPT® book but when I’m stuck, I regularly find answers there. And wish I had started looking there in the first place!
What about CMS? CMS has edits in place to ensure that an add-on code is only paid when reported with a correct primary code. Naturally, they have three levels of edits but you can read about this on the CMS website.
I think the question was prompted by the fact that for certain services provided by practitioners in a facility the add-on prolonged care codes includes time the days before or in the days after the face-to-face encounter. You can see the chart from the CMS final rule and read about it here.
I don’t know what edits individual MACs are setting up for these codes, but I recommend that you continue to submit all add-on codes on the claim with the primary code, following CPT® rules and CMS guidance.
The non-face-to-face prolonged care codes are still active, billable codes. But, they may not be reported on the same date of service as 99202-99215 per CPT®. And, Medicare has given them a status code of invalid, which means they won’t pay for it. And, there is not a replacement code for this service for Medicare.
Question:
I understand from your article about prolonged services in 2021 that CMS won’t pay for prolonged code 99417 and instead developed a HCPCS code for the service. (G2212) Do you have any recommendations about how to manage this in the office?
Answer:
Although in general, I believe most clinicians can code for most of the work they do (not a universally held opinion, I know) this is a case where the claims must go to a coder for review. Not only are there different codes depending on payer, the time thresholds are different. CPT® allows you to add the 15 minutes to the lower time threshold in the range, and CMS requires you to add the 15 minutes to the higher time threshold in the range.
Just a few reminders. The prolonged codes can only be used on 99205 and 99215, and only when time is used to select the office visit code. The total time must be documented. CMS’s manual does not currently require start and stop times. Look for a description of what activities are included in the time, because this is required when using time to select the office visit codes. “I spent 90 minutes caring for the patient today. It included reviewing test results, documenting in the record and arranging for follow up at pain management. It also included an extensive discussion with the patient and his sister about treatment options and recovery time, if he decides on surgery.”