Prolonged Services in CPT® versus Medicare: They Do not Agree

The code 99417 is invalid for Medicare and MA reimbursement.

When the CPT® Guidelines were updated for 2021, one of the options for leveling an office or other outpatient evaluation and management (E&M) service was to use time as the leveling agent. The time thresholds for each E&M office visit were also changed from “typical” time to a range of time for each level of service (see chart below). The goal of the American Medical Association (AMA) was to have more exact times documented for patient encounters when that metric was used to support the visit. The time that is counted is the total time on the same date as the face-to-face for each patient encounter.

In addition to the redefined time component, counseling and/or coordination of care does not have to dominate the visit, as before, to qualify for a time-based code. However, the CPT® book is clear that activities provided during a time-based encounter should be listed in some format.

• Per Noridian Medicare, “when using time to level an E&M, the time statement must be documented by provider within the note and must state their best estimate of the exact time spent in care of the patient on the date of the encounter.”

What can be listed in the time for an office or other outpatient visit includes:

• Preparing to see the patient (e.g., review of tests and images, same date from external sources);
• Obtaining and/or reviewing separately obtained history;
• Performing a medically appropriate examination and/or evaluation;
• Counseling and educating the patient/family/caregiver;
• Ordering medications, tests, or procedures;
• Referring and communicating with other healthcare professionals (when “not separately reported”);
• Documenting clinical information in the electronic or other health record;
• Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver; and
• Care coordination (not separately reported).

Time is based on the total time (both face-to-face and non-face-to-face) personally spent by the provider or qualified health professional (QHP) on E&M services on the date of the encounter. A few things to remember include the following:

• The provider does not have to be in a specific location in order to count the time.
• The time on the date of service does not have to be consecutive.
• The provider may list only time spent uniquely for one patient, and may not list the same period of time for more than one patient.
• Time may be used whether or not counseling and/or coordination of care dominates the service.
• Time is based on a range, and the range is exact, not “typical time,” as previously stated. The physician needs to document exact time if leveling their visit based on time.
• Start and stop times are not required to be documented, nor is it necessary to itemize times spent on each different activity; however, it is recommended to add a statement of time with included activities to support your level of service if ever audited. Providers should not list a range of time, as this can appear to be a “cut and paste” of the CPT® book or the electronic medical record (EMR) template.
• According to CPT®, “the appropriate time should be documented in the medical record when it is used as the basis for code selection.”
• If time is not documented, or there is insufficient time for the minimum code, MDM (medical decision-making) must be used to level the encounter.

CPT® Time Ranges for Office and Other Outpatient Visits

The E&M office and other outpatient codes are not the only codes that got a face-lift from the  2021 changes; so did the prolonged service add-on codes. The existing codes, 99354-99357, continue to be valid, but there is a parenthetical direction in CPT® indicating that they may not be used with the codes 99202-99215. However, AMA and Medicare understand that there may be a circumstance in which the physician or QHP may exceed the maximum time on a Level 5 visit when seeing a patient, and they should be paid for that extra time. Once again, CMS defines total time as “the sum of all time, including prolonged services time, that the reporting practitioner spends on the date of service.”

However, this point of a specific prolonged service code being dedicated to the Level 5 new or established patient visits has a contradiction in terms of its application.

First, AMA/CPT® directs that once the “minimum” time threshold is met, an additional 15 minutes above the minimum time threshold of 40 minutes for a level 99215, or 60 minutes for a 99205, can be applied. Then the new 2021 prolonged service add-on code, 99417, can be added to the Level 5.

An example for a commercial payer would be: the first unit is billable at 55 minutes for 99215, and 75 minutes for 99205.

Medicare strongly disagreed with the application of the new code. My guess would be that this is because of the almost 18 percent increased relative value units (RVUs) for the office and other outpatient visit codes. RVUs were heavily based on time, so in theory, it could be considered double-dipping if additional time was allowed to be charged for a visit that had not yet exceeded its stated time.

CMS has stated that once the “maximum” time in the Level 5 code ranges were met, then and only then could their crosswalk, HCPCS add-on code G2212, be appended to either of the Level 5 office visit codes.

AMA and CMS could not agree on this concept, so CMS created its own code to make sure that their Medicare Administrative Contractor (MAC) carriers and Medicare Advantage (MA) plans clearly understood their position. The 99417 is invalid for Medicare and MA reimbursement.

So, what is the breakdown on when the prolonged service codes can be used?

Prolonged Office/Outpatient E&M Visit Reporting – New Patient

 Prolonged Office/Outpatient E&M Visit Reporting – Established Patient

Remember, the total time is the sum of all time, with and without direct patient contact, including prolonged time, spent by the reporting practitioner on the date of service for the encounter.

Documentation about the duration and content of medically necessary E&M services and prolonged service(s) billed is required in the medical record. The medical record must be appropriately and sufficiently documented by the physician or qualified non-physician practitioner (NPP) to show that the physician or qualified NPP personally furnished the direct face-to-face time with the patient specified in the CPT code definitions.

The start and end times or total time of the visit should be documented in the medical record, along with the date of service.

Programming Note: Listen to Terry Fletcher report this story live today during Talk Ten Tuesdays, 10 Eastern.