Prolonged Evaluation & Management codes underwent big changes in 2021, including the creation of a new prolonged code (99417), reportable only with codes 99205 or 99215.
While Medicare has agreed to accept the AMA's CPT E/M coding changes, they have formulated an opinion contrary to how CPT calculates time specific to reporting this prolonged service code, and have created a separate HCPCS code (G2212) for reporting prolonged services specific to 99205 and 99215. This warrants a quick review of the guidelines and criteria required for reporting this prolonged E/M service, as follows:
Prolonged Codes Specific to 99205 and 99215:
For private payers who do not follow the Medicare guidelines, the appropriate code for reporting prolonged E/M services for office or other outpatient E/M services is 99417. However, for Medicare beneficiaries or payers that publish a policy stating they follow Medicare's guidelines for prolonged services reporting, the code to report would be G2212. Remember that these codes may only be reported with 99205 or 99215.
Medical Necessity
For Medicare, medical necessity is the overarching criteria, in addition to component scoring, used to determine the level of E/M service. If the patient's condition does not warrant a 99205 or 99215 level of care, then it does not matter how long the provider spent caring for the patient, G2212 technically should not be reported. If, however, the patient's condition and the documentation supports a level five (99205 or 99215) level of service, and exceeds the upper limit of the time range, then HCPCS code G2212 would be reported.
Some Medicare Administrative Contractors (MACs) and commercial plans may require start and stop times (e.g., Novitas) while others may allow the total time to be documented.
A few important rules to remember:
- Time is calculated only for time spent on the day of the E/M encounter (not the day before or days following, even if additional services are provided on those days. According to the AMA, the E/M work expense value already takes into consideration time spent caring for the patient (e.g., phone calls, prescriptions, questions, calling patient with test results) for the three days prior to and seven days following the actual E/M service, so if time spent performing these services was counted in addition to the time spent on the actual date of the encounter, this would be considered double dipping.
- Once the total time has been calculated, and the service level has been determined to be high risk, then subtract either the 74 minutes (99205) or 54 minutes (99215) from the total time and the time remaining is used to determine the number of units reportable for either 99417 or G2212.
- Example: An established patient, high risk E/M service took a total of 68 minutes. The provider documented the service, including the severity of the patient's condition and decision to admit to the hospital based on EKG and chest x-ray findings positive for pneumonia.- Subtract the upper end of the time range for an established patient E/M (99215 - 54 minutes) from the total time (68-54 = 14 minutes). The remaining 14 minutes can then be applied towards a prolonged service code.- If this is a Medicare patient, the 15-minute threshold has not been met, therefore it does not qualify for G2212 and would simply be reported as 99215.- If this was a private payer who does not follow Medicare guidelines, then the 14 minutes of prolonged time would qualify for one unit of 99417 and the service would be reported as 99215 (1 unit) and 99417 (1 unit).
Document How Physician/QHP Time Was Spent
The following are a few reasons why instituting a best practice compliance policy of documenting what the physician/QHP spent their time doing with the patient is important:
- Legal issues: If the provider had to defend themselves in a court case, it would be very important for them to be able to easily identify the services, education, advice, or recommendations that were discussed during the encounter.
- Transfer of Care: If the patient's care was being transferred to another provider, the information contained within this record describing the services, recommendations, treatments, or other issues would be of great value.
- Internal/External Audits: When trying to determine whether or not the level of service qualified as a level five (5) service (high risk), an auditor would be looking for key words such as complicated, severe, risk of death, organ failure, or dysfunction. Without documentation to support the level as high risk, a prolonged code may not even be applicable, as the level of service must, first and foremost, be a high-level (level 5) service represented by 99205 or 99215.
For more tips, coding scenarios, and resources for your E/M reporting, consider purchasing the 2021 E&M Book Bundle. This bundle includes the E/M quick reference card, a great tool for quickly identifying the different criteria and time ranges associated with the new E&M coding changes.
Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content for FindaCode. Findacode.com.