Pediatric 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 74 minutes. Can I use +99417 to account for the extra E/M time?

Georgia Subscriber

Answer: In this case, no. You should only 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.).

Why: Per the wording for +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 … each 15 minutes of total time…), CPT^® tells you to begin calculating prolonged services after the level-five office/outpatient E/M goes beyond the minimum threshold for the codes (60 minutes for a new patient 99205 visit and 40 minutes for an established patient 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.) visit.

As the minimum required time for 99205 is 60 minutes, the 15-minute threshold for +99417 means prolonged services do not begin until 75 minutes. And, as this encounter lasted 74 minutes, the E/M service does not meet the threshold, so 99205 is the only code you should report in this situation.