CPT is a trademark of the AMA. 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. LICENSE FOR USE OF "PHYSICIANS' CURRENT PROCEDURAL TERMINOLOGY", (CPT) CodingIntel was founded by consultant and coding expert Betsy Nicoletti. FOURTH EDITION. Medicare and the AMA do not agree on how to define the time factors of "prolonged service". 0760 Specialty Services General 0761 Treatment Room 0769 Other Specialty Services . # 99417 Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services), (Use 99417 in conjunction with 99205, 99215, 99245, 99345, 99350, 99483) 99223, 99233 use time only on date of visit. G2212 Prolong outpt/office vis 0.96 $32.24 0.97 $33.85 -4.7% 0.93 $31.23 0.93 $32.45 NEW CODE . The responsibility for the content of this file/product is with Noridian Healthcare Solutions or the CMS and no endorsement by the AMA is intended or implied. However, CMS and the AMAare not in agreementabout the use of prolonged care code 99417, resulting in HCPCS code. For 2023, CPT removes the words beyond the minimum required time from the descriptor for +99417, which now reads (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)). Consistent with CPTs approach, we do not assign a frequency limitation. CPT is a registered trademark of the American Medical Association. The2023 time file is here. CMSs manual does not currently require start and stop times. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. 4. (Do not report G0316 for any time unit less than 15 minutes). (Do not report 99417 on the same date of service as 90833, 90836, 90938, 99358, 99359, 99415, 99416) Medicare Administrative Contractors (MACs) will process claims per the Internet Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 12, section 30.6.15. The Centers for Medicare & Medicaid Services (CMS) has made several changes to how youll code prolonged services in the last few years. Add This New CPT Prolonged Service Code It also included an extensive discussion with the patient and his sister about treatment options and recovery time, if he decides on surgery.. More details about these office/outpatient E/M changes can be found at CPT Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services . (Do not report 99418 for any time unit less than 15 minutes). If the provider spends less than 15 additional minutes, do not report G2212. 3M takes your privacy seriously. Prolonged services codes may only be added to the highest-level code in the category. The AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. What about CMS? I dont 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. For Medicare patients, there is a HCPCS code. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare and Medicaid Services (CMS). Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. . For Medicare patients, the time thresholds to add G0316 are different than those in our CPT books. Don't use CPT codes to report these services. o New CPT code 99417 can be reported for each 15 minutes of prol onged care performed on the same day beyond the maximum time listed for E/M codes 99205 and 99215. 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 CPTbook. Whether its the changes CMS implemented to prolonged service coding with the 2023 final rule, or the different ways Medicare and payers who follow CPT guidelines code for prolonged services, things are getting tricky when trying to report these services. Do not report G0316 for any time unit less than 15 minutes. You cant report the new add on code on the same day as psychotherapy, non-face-to-face prolonged care codes 99358, 99359 or staff prolonged care codes. Last Updated Wed, 22 Mar 2023 12:22:35 +0000. And wish I had started looking there in the first place! Its the place for leaders to [], March 29, 2023 / By Garri Garrison, Kelli Christman, I sat down with the 3M Health Information Systems Division President Garri Garrison to talk about the upcoming HIMSS show in Chicago and what you can expect at the 3M [], Barbara Aubry, RN, CPC, CPMA, AAPC Fellow, CHCQM, FABQAURP is a senior regulatory analyst for 3M Health Information Systems. When they were applicable to all levels of service, the threshold time was different for each code. We NEVER sell or give your information to anyone. CPT still has non-face-to-face prolonged care in the CPT book, codes 99358, +99359 which can be used on days that do not include a face-to-face visit. Cancel anytime. The typical time for this code is 60, making the threshold time to add a prolonged care code 75 minutes. CPT also deletes prolonged service codes +99356 and +99357 for 2023 and introduces another code: +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 ), which had been previously give the placeholder code of 993X0. The source of this chart is CMSs 2023 Final Rule. Medicare has assigned a status indicator of invalid to code 99417, and developed a HCPCS code to replace it, G2212, If using either code, only report it with codes 99205 and 99215, use only clinician time, and use it only when time is used to select the code, Use for time spent face-to-face and in non-face-to-face activities, preparing to see the patient (eg, review of tests), obtaining and/or reviewing separately obtained history, performing a medically appropriate examination and/or evaluation, counseling and educating the patient/family/caregiver, ordering medications, tests, or procedures, referring and communicating with other health care professionals (when not separately reported), documenting clinical information in the electronic or other health record, independently interpreting results (not separately reported) and communicating results to the, care coordination (not separately reported). G2212 is to be used for billing the MPFS instead of CPT code 99358, 99359 or 99417, with the following descriptor: "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 Practitioners should not report prolonged office/outpatient E/M visit time using CPT codes 99354 and 99355 (Prolonged service with direct patient contact), 99358 and 99359 (Prolonged service without direct patient contact), 99415 and 99416 (Prolonged clinical staff services), or 99417 (Prolonged office/outpatient E/M services with or without direct patient contact), HCPCS code 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). G0318 (Prolonged home or residence evaluation and management service(s) beyond the total time for the primary service each additional 15 minutes ) for prolonged home or residence E/M service codes 99345 and 99350 For Medicare, medical necessity is the overarching criteria, in addition to component scoring, used to determine the level of E/M service. Information provided by our coding experts is copyrighted by the American Academy of Ophthalmology and intended for individual practice use only. 99223 (Initial hospital inpatient or observation care 75 minutes must be met or exceeded) In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. 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 But, they may not be reported on the same date of service as 99202-99215 per CPT. Fortunately, the guidelines for using the code remain the same. Fifteen minutes extra time is required to report one unit of G2212. Use HCPCS Code G2212. For both, howevever, you can only count time that requires practitioner knowledge and expertise. However, the Medicare PFS rule only approves this code for Medicare reimbursement, which comprises just 10 - 15% of many allergy practices. Instead, use G2212, G0316, G0317, and G0318 . Yes. The CMS advisory includes a lengthy explanation of this determination, which I encourage readers of this blog post to review in full. The Centers for Medicare & Medicaid Services (CMS) has made several changes to how youll code prolonged services in the last few years. The Centers for Medicare & Medicaid Services [], CMS and CPT still at odds over when to add extra time. Before you can enter the Noridian Medicare site, please read and accept an agreement to abide by the copyright rules regarding the information you find within this site. Medicare & Payers Adopting Medicare Guidelines. She has been a self-employed consultant since 1998. 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). Thirty-five minutes with a patient would be reported as two units of G2212, etc. 99245 (Office or other outpatient consultation for a new or established patient ) when the time meets or exceeds 55 minutes Use time one day before visit, date of visit and three days after visit, IP/Obs. 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, 99483 for office or other outpatient evaluation and management services). She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. In other words, 1-14 additional minutes of E/M service does not warrant a unit of G2212. As we learn more, we will continue to provide updates on this important topic. In particular, the add-on prolonged services HCPCS codes developed by CMS. You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. (Do not report G2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416). Copyright American Medical Association. This warning banner provides privacy and security notices consistent with applicable federal laws, directives, and other federal guidance for accessing this Government system, which includes all devices/storage media attached to this system. For other services (hospital, nursing facility and home and residence services), CPT uses the times stated in the CPT book for the primary code when calculating if a prolonged services code may be added. You are using an out of date browser. The provider documented the service, including the severity of the patient's condition and decision to admit to the hospital based on EKGand chest x-ray findings positive for pneumonia. y{O? %vYt{D&P*iI 00v3f|ti!lL3>"A@^N]LV``>rg "MUc`ZQ` a Prolonged service time can be reported when furnished on any date within the primary visits surveyed timeframe, and includes time with or without direct patient contact by the physician or NPP. In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. Required fields are marked *. First, consult the Clip & Save guide elsewhere in this article, then determine how you would code for inpatient care lasting 95 minutes for a patient who has just been admitted to the hospital. Any resource shared within the permissions granted here may not be altered in any way, and should retain all copyright information and logos. Subscribe to receive our FREE monthly newsletter and Everyday Coding Q&A. You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. And, Medicare has given them a status code of invalid, which means they wont pay for it. 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. Once the total time has been calculated, and the service level has been determined to be high risk, then subtract either the 74 minutes (. Below are a few excerpts that I would like to highlight. No charge. Any communication or data transiting or stored on this system may be disclosed or used for any lawful Government purpose. It is always important to properly document, but when a medical necessity audit is looming, be sure to include information that supports the decision making process. The following codes are covered and separately reimbursed when documentation requirements are met: G2212Prolonged 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 %PDF-1.6 % CMS does not recognize 99417 for Medicare Advantage members. (Do not report G0318 for any time unit less than 15 minutes)). CPT Code Description for 99417 The AMA CPT committee developed code 99417 for prolonged visits, and Medicare developed code G2212. In the 2021 final rule, CMS argued that you should use +99417 when the total time for visits hits 15 minutes beyond the maximum time range for 99205 (i.e., 89 minutes) and 99215 (i.e., 69 minutes). The time reported must be 15 minutes, not 7.5 minutes. There are times in which the various content contributor primary resources are not synchronized or updated on the same time interval. When can I bill prolonged services code 99417? This includes items such as CPT codes, CDT codes, ICD-10 and other UB-04 codes. 99345/99350 (Home or residence visit for the evaluation and management of a new/established patient ) when the times meet or exceed 75 or 60 minutes, respectively For instance, time spent waiting on hold, leaving a message, etc., are not counted. 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). You acknowledge that the AMA holds all copyright, trademark, and other rights in CPT. The CPT Editorial Panel's guidance was that prolonged services could be billed after a visit exceeds the minimum level 5 threshold by 15 minutes. 371 0 obj <>stream Coding for Evaluation and Management Services: Answers to Common Questions Evaluation and management (E/M) services are at the core of most family medicine practices and represent a category. CPT codes 99417 and 99418 will be denied with one of the following: Denial explanation code: 53B This procedure code is not accepted for processing by Moda Health for These are important qualifiers, as medical necessity audits are likely to follow. Effective January 1, 2021, CMS finalized HCPCS code G2212 for prolonged office/outpatient E/M visits HCPCS code G2212 is to be used for billing instead of CPT codes 99354, 99355, 99358, 99359 or 99417 Defined as prolonged office or other outpatient evaluation and management CDT is a trademark of the ADA. HCPCS G2212 (for CMS patients) is reported only in addition to CPT 99205 and 99215. 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. Our expert staff have decadesof combined experience, covering all aspects of coding and reimbursement. CMS is warning that use of G2211 is not expected on claims containing modifiers 24, 25 and 53. For hospital, nursing facility and home and residence services, CMS uses time on other dates of service. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Recently, I discussed a couple of the more commonly encountered types of posterior instrumentation for spinal fusion procedures (posterior instrumentation). However, for a Medicare patient, you would not be able to bill 99223 with G0316 in this situation as even though 99223 may have been exceeded by 15 minutes, the codes descriptor tells you not to report G0316 for any time unit less than 15 minutes. In this case, the unit of the prolonged service time, 5 minutes, is less than 15 minutes, so you will only bill Medicare for the 99223 service. CMS use the time in the. You must log in or register to reply here. It may not be reported with psychotherapy or non-face to face prolonged care codes, or discharge services 99238, 99239, 99315, 99316. The information below is what was sent to us from our Medicaid program. Expect audits of all E/M claims that use time as the determining factor in choosing a code. E/M 2023: Extend Prolonged Service Smarts With New Codes, Extend Prolonged Service Smarts With New Codes, Whether its the changes CMS implemented to prolonged service coding with the 2023 final rule, or the different ways Medicare and payers who follow CPT, Fortunately, the guidelines for using the code remain the same. If the patient has private insurance, you would bill 99223 and +99418 as +99418 may be used as soon as the total time [75 minutes] has been exceeded by 15 minutes, according toKelly Loya, CPC, CHC, CRMA, CPhT, CHIAP, associate partner at Pinnacle Enterprise Risk Consulting Services, Charlotte, North Carolina. The use of the information system establishes user's consent to any and all monitoring and recording of their activities. These do not follow the CPT mid-point time rule. All rights reserved. Prolonged services codes are add-on codes to E/M services. Additionally, be sure to clearly document the amount of time . Watch this webinar about all these changes. Health information management (HIM) professionals are [], Each year 3M brings together some of the brightest minds in health care, clinical documentation and health information management at our annual 3M CES. When a [], Allergic Arthritis Dx Nothing to Sneeze At, Question:Encounter notes indicate that a patient suffered from allergic arthritis, R ankle. Is this a [], Know Purpose of Shoulder Arthroscopy Before Coding, Question:Encounter notes indicate that the provider performed a level-four office evaluation and management (E/M) service [], Get Off on Right Foot With F/T Modifier Coding, Question:Im relatively new to orthopedic coding, so a couple of the modifiers Im familiarizing myself [], Copyright 2023. CMS DISCLAIMER. 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 CPTcodes 99223, 99233, and 99236 for hospital inpatient or observation care evaluation and management services). G0316 (Prolonged hospital inpatient or observation care evaluation and management service(s) beyond the total time for the primary service each additional 15 minutes ) for prolonged inpatient or observation E/M service codes 99223, 99233, and 99236 Remember G Codes for Medicare Patient Prolonged Services It doesnt follow CPT typical times, or CPT prolonged services rules. You may also contact AHA at ub04@healthforum.com. You can see the chart from the CMS final rule and read about it here. Prolonged services for labor and delivery are not separately reimbursable services. However, Medicare does not cover 99417 and, instead, created HCPCS code G2212 to report this service. CMS added two HCPCS codes to represent additional time for E/M services. Remember that these codes may only be reported with 99205 or 99215. HCPCS code G2211 may be reported with any visit level. I understand from your article about prolonged services in 2021 that CMS wont pay for prolonged code 99417 and instead developed a HCPCS code for the service. The medical record must be appropriately and sufficiently documented by the physician or qualified Non-Physician Practitioner (NPP) to show that the physician or qualified NPP. The CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. CMS does not recognize consult codes. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. BY CLICKING ABOVE ON THE LINK LABELED "I Accept", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THESE AGREEMENTS. In their place, youll now use +99417, as CPT has increased its scope. IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THESE AGREEMENTS CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. 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. The ADA does not directly or indirectly practice medicine or dispense dental services. LICENSE FOR NATIONAL UNIFORM BILLING COMMITTEE ("NUBC"), Point and Click American Hospital Association Copyright Notice, Copyright 2021, the American Hospital Association, Chicago, Illinois. Time spent speaking to a licensed professional on the phone for peer-to-peer review would count. 99231 -99233 Evaluation and Management Services 99 238 -99499 Evaluation and Management Services 2. 1. Discover how to save hours each week. JavaScript is disabled. However, for Medicare beneficiaries or payers that publisha policystating they follow Medicare's guidelines for prolonged services reporting, the code to report would be G2212. CDT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. (Do not report 99418 on the same date of service as 90833, 90836, 90838, 99358, 99359) by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MTFeb3rd,2021. Effectively, it is so byzantine that most practices will never be able to bill for them. If this is not an edit in the software system you use, speak with your vendor and ask that it be created for Medicare claims only. Biomechanical device placement and anterior instrumentation, Celebrating health information professionals, Top 6 reasons to attend the 2023 3M Client Experience Summit, Three questions with Garri Garrison: From pen and paper to hands free, COVID-19 compliance concerns Part 2 on PPE. Making copies or utilizing the content of the UB-04 Manual or UB-04 Data File, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual / Data File or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. Effectively, all prolonged services coding will need to be done by coders. Bone Up on +99417 Definition Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). If you do not consent to this use of your personal information, please do not use this system. (Do not report G0317 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99418,). MACs may be instructed to focus on specific codes or diagnoses, or even specific extra time units reported. Applications are available at the American Dental Association web site, http://www.ADA.org. I spent 90 minutes caring for the patient today. 327 0 obj <> endobj Feb. 15, 2021 / By Barbara Aubry, RN. 3M and its authorized third parties will use the information you provided in accordance with our privacy policy to send you communications which may include promotions, product information and service offers. Criteria for Using and Submitting CPT Code G2212: Primary E/M service CPT Code 99205 or 99215 is selected based on time and NOT medical decision making and the service was 15 minutes or more Services must be Medically Necessary during the prolonged E/M service. G2212 effective January 1st, 2021. This system is provided for Government authorized use only. There is no replacement code. All rights reserved. Note: The information obtained from this Noridian website application is as current as possible. To avoid potential confusion with CPT guidelines, CMS created a new prolonged service code, recognized by Medicare and payers following Medicare payment rules, to take its place: 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 ). Do not report G0317 for any time unit less than 15 minutes. 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. The entire 15 minutes must be done, in order to add on this new, prolonged services code. coding guidance prior to the submission of claims for reimbursement of covered services. HCPCS code G2212 is as follows, "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 THE LICENSES GRANTED HEREIN ARE EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THESE AGREEMENTS. Does anyone have any concrete information regarding these additional codes we can use for prolonged E/M Services. Your email address will not be published. Whether its the changes CMS implemented to prolonged service coding with the 2023 final rule, or the different ways Medicare and payers who follow CPT guidelines code for prolonged services, things are getting tricky when trying to report these services. The prolonged codes can only be used on 99205 and 99215, and only when time is used to select the office visit code.
