Orthopedic Coding Alert

Question: Our provider performed an office evaluation and management (E/M) service for a new patient. It was an extensive encounter; there was high-complexity medical decision making (MDM) and the visit lasted 84 minutes. Can I use the new prolonged service code to account for the extra E/M time?

Alabama Subscriber

Answer: In this case, no. You should report 99205 (Office or other outpatient 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 time for code selection, 60-74 minutes of total time is spent on the date of the encounter.) for the E/M service and nothing more.

No prolonged services? The descriptor for the new office/ outpatient code for prolonged services, +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)), forbids reporting the code in this instance.

Why? You didn’t reach the 15-minute threshold that the descriptor indicates you need to achieve to properly report +99417. Unless this service lasted at least 89 minutes, you cannot report +99417.