How To Properly Report Prolonged Services Using 99417 or G2212

by  Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
February 3rd, 2021

Prolonged Evaluation & Management codes underwent big changes in 2021, including the creation of a new prolonged code (99417), reportable only with codes 99205 or 99215. While Medicare has agreed to accept the AMA's CPT E/M coding changes, they have formulated an opinion contrary to how CPT calculates time specific to reporting this prolonged service code, and has created a separate HCPCS code (G2212) for reporting prolonged services specific to 99205 and 99215. This warrants a quick review of the guidelines and criteria required for reporting this prolonged E/M service, as follows: 

Prolonged Codes Specific to 99205 and 99215:

For private payers who do not follow the Medicare guidelines, the appropriate code for reporting prolonged E/M services for office or other outpatient E/M services is 99417. However, for Medicare beneficiaries or payers that publish a policy stating they follow Medicare's guidelines for prolonged services reporting, the code to report would be G2212. Remember that these codes may only be reported with 99205 or 99215

Medical Necessity

For Medicare, medical necessity is the overarching criteria, in addition to component scoring, used to determine the level of E/M service. If the patient's condition does not warrant a 99205 or 99215 level of care, then it does not matter how long the provider spent caring for the patient, G2212 technically should not be reported. If, however, the patient's condition and the documentation supports a level five (99205 or 99215) level of service, and exceeds the upper limit of the time range, then HCPCS code G2212 would be reported.

CODES

MINUTES

PAYER

99205

60-74

All

99205 + 99417

75-89

Non-Medicare Payers

99205 + G2212

89-103

Medicare & Payers Adopting Medicare Guidelines

99215

40-54

All

99215 + 99417

55-69

Non-Medicare Payers

99215 + G2212

69-83

Medicare & Payers Adopting Medicare Guidelines

Some Medicare Administrative Contractors (MAC) and commercial plans may require start and stop times (e.g., Novitas) while others may allow the total time to be documented.

A few important rules to remember: 

Document How Physician/QHP Time Was Spent

The following are a few reasons why instituting a best practice compliance policy of documenting what the physician/QHP spent their time doing with the patient is important:

For more tips, coding scenarios, and resources for your E/M reporting, consider purchasing the 2021 E&M Book Bundle. This bundle includes the E/M quick reference card, a great tool for quickly identifying the different criteria and time ranges associated with the new E&M coding changes.  

How To Properly Report Prolonged Services Using 99417 or G2212. (2021, February 3). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/how-to-properly-report-prolonged-services-using-99417-or-g2212-36784.html

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