Three Things To Know When Reporting Prolonged Services in 2023

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Jan 31st, 2023

Click HERE to register for this FREE webinarThe 2023 Evaluation and Management (E/M) changes are significant and impactful and to ensure organizations have a solid knowledge of how to report these services correctly, we will focus on three key points that should be understood: 

1. CPT and Medicare report prolonged services using different codes
2. CPT calculates time differently than Medicare
3. Other payers will follow Medicare guidelines 

In 2021, Medicare disagreed with the CPT guidelines specific to the times when prolonged services should begin being reported and now, in the 2023 E/M changes, Medicare once again disagrees as well. Here are three things you should know before reporting prolonged service codes 99417 and 99418:

CPT and Medicare report prolonged services using different codes

CPT has provided two new codes for reporting prolonged services:

99417 (added in 2021) is used to report prolonged services for the following codes: 99205, 99215, 99245, 99345, 99350, and 99483; all services performed in the office or outpatient setting. Because Medicare disagrees with the CPT guidelines for reporting prolonged services, they have published G2212 for reporting outpatient prolonged services with those same primary CPT codes.

In 2023, CPT published code 99418 for reporting prolonged services in the inpatient or observation setting with primary codes 99223, 99233, 99236, 99255, 99306, and 99310. Because Medicare disagrees with the CPT guidelines for when prolonged codes may begin being calculated, it has developed three codes to replace 99418, as well as a different set of guidelines:

• G0316 Inpatient and Observation Care prolonged services
• G0317 Nursing Facility prolonged services
• G0318 Home and Residence prolonged services 

CPT calculates time differently than Medicare

With the deletion of approximately 25 E/M codes, the RVS Update Committee (RUC) began resurveying the remaining E/M codes and provided recommendations to CMS, which included preservice, intra-service, and post-service times. These RUC recommendations and times were used by CMS to develop the guidelines for reporting prolonged services, creating a need for different codes and different guidelines than CPT had published.

CPT assigned specific time ranges to codes 99202-99215 and single times to Other E/M services. For codes 99205 and 99215, the highest level in their respective E/M categories, there is a minimum and maximum time 99215 (40-54 minutes). When calculating time to report prolonged services code 99417, CPT guidelines indicate to begin with the minimum time in the time range, add 15 minutes, and report the initial unit of 99417 at 55 minutes. Medicare, on the other hand, requires the maximum time in the time range to be met, exceeded by 15 minutes, and then counting of the 15 minutes of prolonged time may begin.

Total Provider Time:78 minutes

Scoring: 

• CPT guidelines allows one unit of 99417 at 55 minutes, beginning the prolonged service time clock at the minimum time in the time range (40 minutes). This means at 55 minutes the first unit of 99417 is reported and at 70 minutes, the second unit of 99417 is reported. Final Codes: 99215, 99417 x 2 units.
• Medicare guidelines allow one unit of G2212 at 70 minutes, beginning the prolonged service time clock at the maximum time in the time range (54 minutes). This means that at 54 minutes another 15 minutes must be exceeded before the initial unit of G2212 can begin to be counted. That time between 54-69 minutes does not garner a unit of G2212 but rather the initial unit is allowed at 70 minutes completed.
  
  

Other Payers May Follow Medicare Guidelines

Although Medicare develops policies specific to claims for services provided to Medicare beneficiaries, many commercial payers adopt them and make them policies of their own. This means whenever scoring prolonged services for a patient it is important to know which payers have published policies stating they will be following Medicare guidelines for coding prolonged services using G2212, G0316, G0317, and G0318. Because there is such an enormous difference between the two sets of guidelines, it could be helpful to maintain these guidelines in a location where they are easily accessible.

Join us for an upcoming webinar where we review the prolonged services guidelines for both CPT and Medicare, including examples of each.  That webinar, "The differences between Medicare and CPT, Reporting Polonged Services" is scheduled for Thursday, Feruary 2, 2023 @ 10:15 AM PT, 11:15 AM MT, 12:15 PM CT, 1:15 PM ET.

Click HERE to register for this FREE webinar.

About Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Aimee L. Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. Aimee believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.