Prolonged services are direct (face-to-face) services provided by a physician or other qualified health professionals that require unit/floor time beyond the usual services in either the inpatient or outpatient setting. A major change in the CY2023 Final Rule that has impacted physician practices and medical billing companies in 2023 is the way prolonged services are coded. AMA and CMS’ requirements differ with regards to the prolonged add-on codes.
Reporting Prolonged Services in 2023 – Key Changes
- Deleted codes: Prolonged services codes 99354, 99355, 99356, and 99357 are no longer in use. In place of codes 99354 and 99355, use 99417. Code 99417 can be used to report prolonged services along with:
- 99245 (Office or other outpatient consultation for a new or established patient …) when the time meets or exceeds 55 minutes
- 99345/99350 (Home or residence visit for the evaluation and management of a new/established patient …) when the times meet or exceed 75 or 60 minutes, respectively
- 99483 (Assessment of and care planning for a patient with cognitive impairment …) when the service goes beyond its typical time of 50 minutes
Non-face-to-face prolonged care codes 99358 and 99359 are still active codes, but Medicare does not recognize them.
- Changes to code 99417 descriptor: CPT removed the words “beyond the minimum required time” from the descriptor for +99417. The new descriptor for+99417 is: Prolonged outpatient evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time (List separately in addition to the code of the outpatient Evaluation and Management service). The guidelines for using this code have not changed. Code+99417 can be used to report prolonged services with:
- 99245 (Office or other outpatient consultation for a new or established patient …) when the time meets or exceeds 55 minutes
- 99345/99350 (Home or residence visit for the evaluation and management of a new/established patient …) when the times meet or exceed 75 or 60 minutes, respectively
- 99483 (Assessment of and care planning for a patient with cognitive impairment …) when the service goes beyond its typical time of 50 minutes
- New CPTProlonged Service Code: There is a new prolonged service code in 2023:+99418 (Prolonged inpatient or observation evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time…). 99418 is for use with:
- initial and subsequent nursing facility care E/M codes 99306 and 99310
- 99223 (Initial hospital inpatient or observation care … 75 minutes must be met or exceeded)
- 99233 (Subsequent hospital inpatient or observation care … 50 minutes must be met or exceeded)
- 99236 (Hospital inpatient or observation care … 85 minutes must be met or exceeded)
- 99255 (Inpatient or observation consultation … 80 minutes must be met or exceeded)
- New Medicare Prolonged Service G-Codes: Effective January 1, 2023, new Medicare G-codes replaced the AMA’s 2023 CPT codes for prolonged services. Depending on their setting, providers can use these new codes in lieu of CPT codes 99356 (Prolonged service in the inpatient or observation setting), and 99357 (Prolonged service in the inpatient or observation setting). These new HCPCS codes are G0316, G0317 and G0318.
- G0316 – Prolonged hospital inpatient or observation care evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using 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
- HCPCS code G0316 should be listed separately in addition to CPT codes 99223, 99233, and 99236 for hospital inpatient or observation care evaluation and management services
- G0316 should not be reported on the same date of service as other prolonged services for evaluation and management 99358, 99359, 993X0)
- Do not report G0316 for any time unit less than 15 minutes
- G0316 has been added to Medicare telehealth services on a Category 1 basis
- G0317 – Prolonged nursing facility evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using 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 G0317separately in addition to CPT codes 99306, 99310 for nursing facility evaluation and management services)
- Do not report G0317 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 993X0
- Do not report G0317 for any time unit less than 15 minutes
- G0317 was added to the Medicare Telehealth Services List on a Category 1 basis
- G0318 – Prolonged home or residence evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using 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 G0318 separately in addition to CPT codes 99345, 99350 for home or residence evaluation and management services
- Do not report G0318 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99417)
- Do not report G0318 for any time unit less than 15 minutes to describe prolonged services associated with certain types of E/M services
- G0318 was added to the Medicare Telehealth Services List on a Category 1 basis
- Codes for office and other outpatient service: The two prolonged services CPT codes for office and other outpatient service are 99417 and HCPCS code G2212. CMS does not recognize (or pay) 99417.
In the 2021 final rule, CMS maintained that+99417 should be used when the total time for visits hits 15 minutes beyond the maximum time range for 99205 (i.e., 89 minutes) and 99215 (i.e., 69 minutes). To take the place of+99417, CMS created a new prolonged service code, recognized by Medicare and payers following Medicare payment rules: 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 …).
Both 99417 and G2212 should be reported when time is used to determine the highest level E/M (99205 or 99215) service performed in the office or provider-based department.
Document Time Correctly
Documenting time correctly is crucial to select the visit level for prolonged services. Here is a chart showing the time thresholds for reporting prolonged services in 2023:
Physicians need to document their visits correctly and understand when their service can and cannot be reported using a prolonged services add on code.
With new codes and coding conventions for prolonged services in 2023, physicians can benefit immensely from outsourced medical coding services. Leading medical coding service providers are knowledgeable about revised codes and code selection facts, and can help physician practices report their services correctly and ensure proper payment.
Since joining our RCM Division in October 2021, Loralee, who is HIT Certified (Health Information Technology/Health Information Management), brings her extensive expertise in medical coding and Health Information Management practices to OSI.