Wiki Prolonged services billing

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sgilbert029

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Hello, I wanted to through this out to the community because we are having a hard time at my proactive getting paid for the prolonged services code 99417. We are billing it with an office visit which has a mod 25 on it. We can get Medicare to pay but are having trouble with commercial payers, especially Blue Cross and Blue shield. Does anyone have any experience with this code and know if we need to be billing it a certain way? Any help is welcome. Thank you!
 
Hi there, I'm surprised to hear Medicare is paying 99417. CMS specifically created G2212 for prolonged services with office/other outpatient E/M codes and lists 99417 as Invalid.

Could your private payers be using the HCPCS code rather than the CPT code?
 
If you check out an older forum posting Prolonged Services there is a message in the thread posted on 01/11/2021 from dkissel which cites a message from BCBS of Michigan notes they do not accept 99417 for prolonged service, they want G2212 for these services. I couldn't find a specific policy about prolonged services that is publicly available for BCBS of Michigan for prolonged services but there was a policy on Spravato billing which states they want G2212 not 99417 for prolonged services. You may want to verify BCBS of Michigan's reimbursement policy on prolonged services to verify what codes they accept for prolonged services.

You might have to create a cheat sheet for the various insurance companies you submit claims to listing which ones want 99417 and G2212. It may be a bit of an investment in time & resources to create the cheat sheet, but it will likely save time & money in the long run if you know which code each carrier reimbursed from the outset because you won't have resubmit claims with the prolonged services code that you didn't use initially.

It is frustrating that CMS didn't follow the AMA and accept 99417 for prolonged services and instead created G2212 for Medicare claims but CMS does what it wants, and we're all stuck with the outcome of their decisions.
 
I would just add a reminder that the threshold time requirements for 99417 and G2212 are different.
 
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