EM Coding Alert

Plus, some facility prolonged services codes involve time beyond the DOS.

Reporting prolonged services is key to ensuring providers are paid for the work they do that goes above and beyond “normal” time expectations for an encounter.

Here are some great tips for reporting prolonged services, including crucial differences in reporting outpatient versus facility prolonged services, from the HEALTHCON 2025 presentation “Prolonged Services” by Betsy Nicolleti, CPC.

Keep POS and DOS in Mind for CPT^®

Prolonged services are add-on codes, so you need a primary or base code — which can sometimes be found within the long descriptor — and that primary code must be selected based on medical decision making (MDM) rather than time. These codes are dependent upon both place of service (POS) and date of service (DOS).

When you need to report prolonged services in addition to evaluation and management (E/M) services, you need to know your patient’s insurance provider (or at least whether they have commercial insurance or Medicare), and where the prolonged services took place. For patients who don’t have Medicare, you need only CPT^® codes.

There are two key CPT^® prolonged services codes, which differ primarily due to setting:

• +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))
• +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))

When reporting these codes, you simply count the time the provider spent on the DOS.

The prolonged services codes may be added only to the highest level of code in any category, excepting +99415 (Prolonged clinical staff service (the service beyond the highest time in the range of total time of the service) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour (List separately in addition to code for outpatient Evaluation and Management service)) and +99416 (Prolonged clinical staff service … each additional 30 minutes ….), she said.

According to CPT^® guidelines, prolonged services may be added for both face-to-face and non-face-to-face time; you can find more specifics in the CPT^® guidelines.

CMS Requires More Constraints

The Centers for Medicare & Medicaid Services (CMS) says prolonged services codes apply only to certain situations involving new and established patients at the highest level of service and cognitive planning, Nicoletti said. They don’t apply to consultations, which CMS doesn’t recognize, nor telemedicine.

CMS developed the HCPCS prolonged services codes to give some wiggle room on the criteria of a full 15 minutes of time, but there’s still some room for conflict when coding, Nicoletti said.

You can see in the descriptors that you’ll still need to report CPT^® codes as your base codes.

There are four key HCPCS codes, which would be used for Medicare beneficiaries, and which also differ depending on the beneficiary’s setting:

• 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, 99415, 99416). (do not report g0316 for any time unit less than 15 minutes))
• 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))
• 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))
• 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, 99483 for office or other outpatient evaluation and management services) (do not report g2212 on the same date of service as 99358, 99359, 99415, 99416). (do not report g2212 for any time unit less than 15 minutes))

For Medicare, You May Need to Look Beyond DOS

One way that these codes differ from the CPT^® prolonged services codes is that you may need to count time beyond the actual DOS.

For example, some hospital inpatient and observation prolonged services codes, like G0316 with 99236 (Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 85 minutes must be met or exceeded.), include time beyond the DOS.

When reporting a provider’s prolonged services in a nursing home with G0317 and base codes 99306 (Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded.) or 99310 (Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.), you count time spent a day before the visit, the day of the visit, and three days after the visit.

Similarly, when reporting G0318, Nicoletti said to include time spent three days before the visit, the day of the visit, and seven days after the visit. Depending on the time the provider spent with a new or established patient, the base code might be 99345 (Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded.) or 99350 (Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.), but CMS says you need to pay attention to time maximums, too. The maximum for a new patient is 140 minutes and, for an established patient, 110 minutes.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC