Urology Coding Alert

E/M 2021:

Highlight Fundamental Differences Between 2 New Prolonged Services Codes

Published on Wed Feb 10, 2021

See why CMS chose to adopt a new code in lieu of the existing +99417.

Over the course of 2020, you’ve witnessed the long, and sometimes strange, evolution of the code that you’ll report for prolonged office or other outpatient evaluation and management (E/M) services. Beginning with the mysterious placeholder code 99XXX, you were eventually introduced to +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)) following the release of CPT^® 2021.

However, as was par with the course for 2020, the turmoil didn’t end there. The Centers for Medicare and Medicaid Services (CMS) made clear in the 2021 Medicare Physician Fee Schedule (MPFS) final rule that code +99417 didn’t satisfactorily convey how to accurately report prolonged services following an office or other outpatient visit. “In the past, getting reimbursed for prolonged office or other outpatient E/M services was difficult,” recounts Judy Smith, CPC, CPB, CPMA, CEDC, CPC-I, medical coding instructor at Fort Myers Technical College, in Fort Myers, FL. “While that’s no longer the case with +99417, the concerns about the wording within the code description have prompted CMS to create their own redefined version of +99417 in the form of a HCPCS Level II code,” Smith explains.

That’s the basis behind CMS’ introduction of code 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 (List separately in addition to CPT^® codes 99205, 99215 for office or other outpatient evaluation and management services)) in the final rule. “You’ll find code G2212 is useful for reporting medically necessary extended high-level care to patients that may include certain education and counseling services,” says John Piaskowski, CPC, CUC, CPMA, CCC, CCVTC, CIRCC, CGSC, CGIC, COSC, CRC, Compliance Coder at Shore Physicians Group in Somers Point, NJ.

As you’ll see, the underlying purpose for these codes is the same, but CMS felt the need to include their own version of +99417 that elaborates on a few points that lack clarity.

Read on for a breakdown of the need for the change, what it means for your practice, and how to implement it in your day-to-day coding.

Consider Their Justification for the Change

CMS outlines in the final rule that the lack of clarity surrounding code +99417 was enough to justify the creation of a brand-new HCPCS Level II code that better conveyed the parameters in which you should report prolonged services following office or other outpatient services. CMS begins by tracing the issue back to the code description for +99417. Specifically, CMS wasn’t satisfied with the portion stating “requiring total time with or without direct patient contact beyond the usual service.” CMS explains in the final rule that “the term ‘total time’ is unclear because office/ outpatient E/M visits now represent a range of time, and ‘total’ time could be interpreted as including prolonged time.” CMS adds that the term “usual service” doesn’t include a concrete definition. This adds to the confusion since there’s no point of reference for when a practitioner exceeds their “usual” allotted time (previously indicated as the total time estimate in the code description).

At first, their point might not be easily decipherable without reading it back a few times. However, the underlying concern lies with the potential for coders to fundamentally misinterpret the +99417 code description so that it results in billing +99417 when the total time criteria has not been met.

CMS explains that, while the wording of the +99417 code description seemingly might leave it open to interpretation, they believe +99417 is meant to be reported for services that extend 15 minutes or beyond the maximum total time range for codes 99205 and 99215. For instance, consider the time range included in each respective code description:

99205: 60-74 minutes
99215: 40-54 minutes

CMS’ concern is that coders may consider any service ending within the aforementioned time ranges to be equally eligible for +99417 consideration. For instance, if a coder is working on a chart in which an established patient visit ends at 46 minutes, the +99417 description leaves open the possibility to simply add the 15 or more minutes beyond where the “usual service” ended at 46 minutes. So, if the coder documents that the provider spent 15 additional minutes of indirect patient contact, the total time spent would only equate to 61 minutes. However, according to CMS, in order to report a prolonged services code, the coder must have documentation of a minimum of 69 minutes. In this instance, the coder would be double counting for a service that’s fully encompassed by 99215.

Ultimately, the underlying concern for +99417 to be misused and misreported led to CMS’ response in creating code G2212. As you can see in the G2212 code description, CMS leaves nothing open to interpretation by revising the description to state “beyond the maximum required time of the primary procedure which has been selected using total time.”

Add in a Few More Essential Details

For Medicare patients, you should exclusively report G2212 for eligible E/M services that meet the required criteria. You should check with other payers for policies on G2212 and +99417 reimbursement. Keep in mind that some commercial payers will not reimburse for prolonged services in any capacity. The Medicare unadjusted fee schedule for G2212 is $31.44 for services that reach 15-29 minutes beyond 99205 and $30.14 for services over 15-29 minutes beyond 99215.

Furthermore, take note that +99417 and G2212 apply to E/M services and procedures performed in an office or other outpatient setting. The code description includes the term “procedure,” but you may code prolonged services with both in-office procedures and/or other office/outpatient E/M services. However, codes +99417 and G2212 may not be billed with any E/M codes other than 99205 and 99215.

Lastly, note that G2212 and 99417 have been added as permanent additions the Medicare telehealth services list.