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Prolonged Services

As of 1/1/2021, CMS has redefined criteria for use of prolonged service codes with evaluation and management services in outpatient settings. Guidance for prolonged services in the inpatient setting remains unchanged.

Outpatient Prolonged Services

For services on and after 1/1/2021, CMS has approved HCPCS code G2212 to represent prolonged service in the office and outpatient settings. G2212 is defined as: 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).

Key Points on HCPCS Code G2212

  • May only be used with office/outpatient services (99205 and 99215) that are billed based on time (not Medical Decision Making – MDM).
  • May only be added to time-based services billed representing the maximum amount of time assigned to the code (i.e., 99205 and 99215).
  • Represents cumulative time (F2F and non-F2F) spent by the provider on the same date of service as the E/M service.
  • Does not include time spent by clinical and ancillary office staff.
  • May not be used to represent time spent on any date before or after the date of the E/M service.
  • Replaces former CPT codes 99354–99356 and 99358–99359, which are no longer permissible in the office and outpatient setting.
  • CMS has not implemented CPT 99417; prolonged service in the outpatient setting may only be represented by G2212.

Inpatient Prolonged Services

In the hospital setting, time spent for a base E/M service may represent both face-to-face and floor time, when all time is relative to the patient’s care and care coordination. Prolonged service, however, must exclusively represent extended time by the rendering/billing provider. Of note, in the teaching hospital setting, time spent by residents in the absence of the attending physician cannot count toward prolonged service.

Key Points on CPT Codes 99356–99357

  • Time spent in the following ways does not count toward inpatient prolonged service and is excluded:
    • Discussing the patient with house medical staff or time spent “rounding” with house staff, when not in direct face-to-face contact with the patient.
    • Time spent waiting for test results, for changes in the patient’s condition, for end of a therapy or for use of facilities.

Examples

The examples below describe appropriate and inappropriate use of prolonged service codes.

Appropriate

  • Patient communication through a language interpreter may prolong time spent in a service, especially for a new patient with a complicated clinical history and presenting problem(s).
  • An office provider treats a patient for an acute asthmatic episode, and the visit is billed based on time as 99215. The provider administered nebulizer treatments and steroidal agents and remained with the patient for a full 70 minutes, until symptoms fully subsided. The time exceeded the maximum time for 99205 (54 minutes) by 16 minutes, so a unit of G2212 is appropriate to represent the prolonged time.
  • A hospitalist spends 25 minutes at the bedside for a hospital visit. On that same day, the same provider (or a same specialty member of his/her group) visits the patient two more times, for episodes of pain and moderate respiratory distress. These two latter visits require an additional 50 minutes of time, for a total of 75 minutes on that date of service. Coding the services as 99233 and 99356 is appropriate.
  • A hospitalist visits a patient on the 3rd day after admission and initially spends time on the unit reviewing the patient’s medical record and recent diagnostic study results over a period of 20 minutes. The hospitalist then proceeds to the patient’s bedside, where he/she performs a detailed examination and lengthy discussion with the patient and family members discussing the diagnostic results and possible treatment options. The total time spent is 80 minutes (20 minutes of unit time and 60 minutes of face-to-face time) and the services billed are 99233 and 99356.

Inappropriate

  • An office patient presents during an acute allergic reaction, and the provider performs a 15-minute visit at the 99213 level and administers a steroid injection. The patient is instructed to sit in the waiting area for 45 minutes, where his condition is monitored by a nurse. Although the patient was in the office suite for more than 60 minutes, face-to-face time with the provider did not meet the level of prolonged service.
  • An office visit is billed at 99215 based on a total time of 45 minutes. Later that same day, the provider holds a phone call with the patient for another 5 minutes and G2212 is added to the claim. In this instance, the total time for the date of service did not exceed the upper limit of 54 minutes for 99215 by 15 minutes or more, so the G2212 is inappropriate.

Prolonged Services: Face-to-Face

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