by Wyn Staheli, Director of Research
February 17th, 2021
In an interesting move by CMS, they created code G2212 to be used INSTEAD of 99417 to report prolonged office Evaluation and Management (E/M) services. This change took place effective January 1, 2021. It should be noted that the proposed Medicare Physician Fee Schedule stated that code 99417 would be used. However, the final rule was different from the proposed rule and said that code G2212 should be used instead.
The rationale behind this change had to do with the allowed times. CMS expressed concern about the use of the word "minimum" in the code description for 99417. The following information comes directly from the final rule and explains their rationale in further detail (emphasis added).
We reviewed our final policy for 2021 regarding the reporting of prolonged office/outpatient E/M visits finalized in the CY 2020 PFS final rule (84 FR 62848 through 62850). To report these visits beginning in 2021, we finalized CPT code 99417 (Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each additional 15 minutes (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services)), which was referred to in our previous rules as temporary CPT code 99XXX. Under CPT prefatory language, CPT code 99417 should only be reported when time is used to select the visit level, and only time of the physician or qualified healthcare professional is counted. In the CY 2020 PFS final rule, we stated that our interpretation of revised CPT prefatory language and reporting instructions would mean that CPT code 99417 could be reported when the physician’s (or NPP’s) time is used for code level selection and the time for a level 5 office/outpatient E/M visit (the floor of the level 5 time range) is exceeded by 15 minutes or more on the date of service (84 FR 62848 through 62849). The intent of the CPT Editorial Panel was unclear because of the use of the terms “total time” and “usual service” in the CPT code descriptor (“requiring total time with or without direct patient contact beyond the usual service.”) The term “total time” is unclear because office/outpatient E/M visits now represent a range of time, and “total” time could be interpreted as including prolonged time. Further, the term, “usual service” is undefined. There is no longer a typical time in the code descriptor that could be used as point of reference for when the “usual time” is exceeded for all practitioners, and there would be variation (as well as potential double counting of time) if applied at the individual practitioner level.
Having reviewed the policy we finalized last year, we believe that allowing reporting of CPT code 99417 after the minimum time for the level 5 visit is exceeded by at least 15 minutes would result in double counting time. As a specific example, the time range for CPT code 99215 is 40-54 minutes. If the reporting practitioner spent 55 minutes of time, 14 of those minutes are included in the services described by CPT code 99215. Therefore, only 1 minute should be counted towards the additional 15 minutes needed to report CPT code 99417 and prolonged services should not be reportable as we finalized last year (see Table 33 of the CY 2020 PFS final rule (84 FR 62849)). Therefore, we proposed that when the time of the reporting physician or NPP is used to select office/outpatient E/M visit level, CPT code 99417 could be reported when the maximum time for the level 5 office/outpatient E/M visit is exceeded by at least 15 minutes on the date of service. In Tables 26 and 27, we provided examples.
Several commenters agreed with our concerns about the lack of clarity in the code descriptor and the potential for double-counting time. Several other commenters disagreed with our proposal and recommended that CMS adopt the CPT code descriptors. These commenters stated that a change in policy by CMS could be confusing to practitioners and disruptive to the ongoing work of medical societies to educate practitioners about the use of these codes. Some commenters also stated the CPT Editorial Panel intended to apply the general CPT rule where practitioners can report a timed code once the midpoint is reached.
The terms “total time” and “usual service” continue to be unclear. While we prefer to align with CPT coding to reduce potential confusion to practitioners, we continue to believe that CPT code 99417 as written is unclear and that allowing reporting of CPT code 99417 when the minimum required time for the level 5 visit is exceeded by at least 15 minutes would result in double counting time. It has not been our understanding that CPT intended for the midpoint time to suffice for reporting this code, and regardless, we did not previously finalize or intend to apply such a policy. We continue to believe it is important for CMS and other stakeholders to know with certainty how much time practitioners spend furnishing office/outpatient E/M visits, in order to assess whether resources are accurately accounted for in their valuation. This is especially true once time can be used to select visit level, with new times established for this code set. To resolve the lack of clarity, we are finalizing our proposal regarding the time that may be counted for prolonged office/outpatient E/M visits; and to resolve the potential inconsistency of our policy with CPT code 99417, we are creating a new HCPCS code G2212 to be used when billing Medicare for this service instead of CPT code 99417, starting in 2021. HCPCS code G2212 is as follows, “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) “(Do not report G2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416). (Do not report G2212 for any time unit less than 15 minutes)).”
We believe the creation of HCPCS code G2212 will serve to resolve the potential differences between Medicare and other interpretations of CPT rules, and better address questions we frequently receive about the required times and what time may be counted toward the required time to report prolonged office/outpatient E/M visits. We also note that we are not opposed in concept to reporting prolonged office/outpatient visit time on a date other than the visit. However, we continue to believe there should be a single prolonged code specific to office/outpatient E/M visits that encompasses all related time (see the CY 2020 PFS final rule for a more detailed discussion of this issue, (84 FR 62849 through 62850)). We will continue to stay abreast of any changes in CPT coding. The valuation for HCPCS code G2212 will be the same as for CPT code 99417.
Please see the article in the References section below for more information about these two codes and a helpful coding table. Our Comprehensive Guide to Evaluation & Management and specialty-specific Reimbursement Guides (available in the online store) provide greater detail on other changes to E/M reporting.