Medicare Compliance & Reimbursement

The new code description for 99202 includes just the essentials: MDM level and a total time estimate. Furthermore, the examining physician should document the “medically appropriate” history and exam portions of the visit, but they have no bearing on your code selection, according to Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York Stony Brook.

The remaining new patient E/M office/outpatient visit codes follow suit with their respective changes to time and MDM:

• 99203 (…low level of medical decision making… 30-44 minutes of total time…)
• 99204 (…moderate level of medical decision making…45-59 minutes of total time…)
• 99205 (…high level of medical decision making… 60-74 minutes of total time…)

Transition to Existing Patient Counterpart Codes

Before breaking down the code descriptors for the established patient set of E/M office/outpatient codes, take note of what’s fundamentally different about the new code description for 99211:

• Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified healthcare professional. Usually, the presenting problem(s) are minimal

Important: The description for 99211 doesn’t include an MDM level or total time estimate. Since it’s the default code for any service that doesn’t qualify for at least 10 minutes of total time spent or a straightforward MDM, there’s no need to cloud the code description with any additional wording.

Here are the remaining respective established patient codes:

• 99212 (…straightforward medical decision making… 10-19 minutes of total time…)
• 99213 (…low level of medical decision making… 20-29 minutes of total time spent…)
• 99214 (…moderate level of medical decision making…30-39 minutes of total time…)
• 99215 (…high level of medical decision making… 40-54 minutes of total time…)

Review Brand-New Prolonged Services Changes

As you process and digest this new set of E/M data, you have one more coding variable to consider — prolonged services.

Remember: In past articles, we touched on the addition of a brand-new prolonged office/outpatient E/M services code that went by the placeholder title of 99XXX (see Medicare Compliance & Reimbursement, Vol. 45, No. 22 & Vol. 46. No. 16).

Now: As of 2021, this code will morph into its final form as +99417 (Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required 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 of total time (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)).

On the surface, this prolonged services code seems rather straightforward. However, there are two additional revised prolonged services code you need to consider:

• +99354 (Prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service; first hour (List separately in addition to code for outpatient Evaluation and Management or psychotherapy service, except with office or other outpatient services [99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215]))
• +99355 (…each additional 30 minutes (List separately in addition to code for prolonged service))

In contrasting the code descriptions between +99417 and +99354, you can deduce that +99354 no longer applies to office/outpatient services within code range 99202-99215. This is a shift from the previous code description, which specifically stated that it was intended for office/ outpatient services in addition to other E/M services outlined in the parenthetical notes.

Keep in mind that you may report code +99417 when working on new or established E/M office/outpatient visits “with or without” direct patient contact. This means that you may include time the provider spends on the patient that extends beyond the typical face-to-face visit.

Coder’s note: “The new guideline for +99417 will state that you should not report the code for any time period less than 15 minutes — meaning you need at least 15 minutes beyond the time allowed for your E/M service within the respective E/M code description,” explains Marie Popkin, CPC, CMCS, BSM, pro-fee auditor at HCCS HIM Services in Fort Myers, Florida. “In other words, you may only report code 99205 for a documented time of 60-74 minutes in 2021. However, after reaching that 75-minute threshold, you may report +99417 for each additional 15-minute interval,” details Popkin.

Consider this: For Medicare Part B patients, you must document the entirety of the 15 (or more) minutes of prolonged services to report code +99417.