EM Coding Alert

Look for descriptor changes that are a bit fiddly.

Make sure you stay abreast of the changes the AMA and Medicare have made for coding prolonged evaluation and management (E/M) services.

Find out the new codes and coding conventions that you should use when coding prolonged services in 2023.

Know the Updated +99417 Definition

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)).

Fortunately, AMA’s CPT^® guidelines for using the code remain largely the same. CPT^® instructs you to use +99417 when service times for 99205 (Office or other outpatient visit for the evaluation and management of a new patient … 60-74 minutes of total time is spent on the date of the encounter) or 99215 (Office or other outpatient visit for the evaluation and management of an established patient … 40-54 minutes of total time is spent on the date of the encounter) go 15 minutes beyond the minimum for the 99205/99215 time ranges — 75 minutes for a new patient visit and 55 for an established patient — and additional units for every 15 minutes beyond those times.

Beware +99417 CPT^® Updates

For 2023, CPT^® also deletes prolonged service codes +99354 and +99355. In their place, you’ll now use +99417, as CPT^® has increased its scope. You’ll now be allowed to use it to report prolonged services in conjunction with:

• 99245 (Office or other outpatient consultation for a new or established patient …) when the time meets or exceeds 55 minutes
• 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
• 99483 (Assessment of and care planning for a patient with cognitive impairment …) when the service goes beyond its typical time of 50 minutes

Don’t Forget to Use G Codes for Medicare

In the 2021 Medicare Physician Fee Schedule (MPFS) final rule, the Centers for Medicare & Medicaid Services (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). 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 the place of +99417: 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 …).

For the 2023 final rule, CMS has taken a similar view of +99418, believing that the billing instructions for the code “would lead to administrative complexity, potentially duplicative payments, and limit our ability to determine how much time was spent with the patient using claims data.” In its place, they have introduced three more G codes:

• 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
• G0317 (Prolonged nursing facility evaluation and management service(s) beyond the total time for the primary service … each additional 15 minutes by the physician or qualified healthcare professional …) for prolonged nursing facility E/M service codes 99306 and 99310
• 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

Consider This Clinical Scenario

Use the Clip & Save Chart on page 2 to determine how you would code inpatient care lasting 95 minutes for a patient who has just been admitted to the hospital. Determine the coding using AMA rules and Medicare rules.

Solution: If the patient has private insurance that applies AMA rules, 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 to Kelly Loya, CPC, CHC, CRMA, CPhT, CHIAP, associate partner at Pinnacle Enterprise Risk Consulting Services, Charlotte, North Carolina.

However, for a Medicare patient, you would not be able to bill 99223 with G0316 in this situation. Even though the 75 minutes listed in 99223’s descriptor may have been exceeded by 15 minutes, the MPFS final rule explains, “The prolonged service period would begin at 90 minutes, 15 minutes beyond 75 minutes. A practitioner would bill HCPCS code G0316 once the 15-minute increment for G0316 is completed, at minute 105.” The example is 10 minutes short of the required 105 minutes, so you will bill Medicare for only the 99223 service.