Primary Care Coding Alert

Question: Our provider performed an evaluation and management (E/M) service on a new patient, then administered Spravato to the patient. The total time for the visit, including the two-hour observation time required for the drug administration, was 225 minutes. I am looking at billing 99205 with 9 units of +99417 for the E/M. Is this correct? Is there a limit to the amount of +99417s I can bill?

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Answer: CPT^® guidelines tell you to add units of +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)) to 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) when time documented hits 15 minutes beyond the minimum for the 99205 time range — in this case, 75 minutes — for your new patient visit.

But this does not mean you can bill for the time spent in the encounter as one unit of 99205 (74 minutes) plus the necessary number of units of +99417 (15 minutes) to reach 225 minutes

First, even if you could document and justify the amount of time a licensed professional spent on a single day performing all the clinical responsibilities of an E/M service with the patient, including performing an appropriate history and/or examination, reviewing the medical record and documenting in it, minus any time billed separately, there is a medically unlikely edit (MUE) of four units on +99417. In other words, the most you could bill for the service would be 99205 + 99417x4 if the payer was using the MUE.

But second, you can probably not bill for the service this way depending on what your provider is doing while the patient is being observed. If the provider is physically present and spends the whole time observing and monitoring the patient, then you may have a case for billing all the time. However, ancillary staff, such as registered nurses (RNs) are responsible for monitoring patients in most observation situations, and the provider will check in with the patient between encounters with other patients. As CPT^® guidelines tell you that you cannot count time for “the performance of other services that are reported separately,” which is what the provider is doing when not observing the patient, you should only report units of +99417 for the actual time beyond the 74 minutes included in 99205 that the provider was with the patient or not otherwise doing some other service that is separately reportable.

As ancillary staff cannot use an office/outpatient E/M to bill for their time, you should reach out to your payer to determine the best way to bill for the extended staff time involved in this encounter. Some payers may allow you to report this with the appropriate use of +99415 (Prolonged clinical staff service…; first hour …) and +99416 (…each additional 30 minutes).