decisionhealth Newsletters, Part B News - 2020 Issue 12 (December)
With HCPCS debut, take note of new rules for prolonged services
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Article Overview
This article is for coders, billers, and compliance staff working with office and outpatient evaluation and management services. It summarizes CMS guidance tied to 2021 reporting changes for prolonged services, the shift from a CPT add-on code to a HCPCS-level alternative for Medicare claims, and limitations affecting non-face-to-face prolonged service reporting. The discussion is relevant to practices that bill time-based E/M services and need to understand how federal policy may differ from payer to payer.
Why This Topic Matters
Prolonged service reporting for time-based office and outpatient E/M visits changed in 2021, and Medicare policy did not mirror CPT guidance. Understanding the new framework helps reduce claim denials, avoid incompatible code combinations, and determine when additional payer-specific review is needed.
Article Sections
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2021 E/M office visits
Overview of the 2021 policy context for office and outpatient E/M services reported by time. The section introduces CMS concerns and the related coding changes for prolonged services.
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99358-99359 curtailed
Discussion of CMS limitations on certain non-face-to-face prolonged service reporting in conjunction with office visits. The section also notes CMS’s stated position on potential future revisions.
What You Will Learn
- How CMS approached prolonged service reporting changes for 2021 office and outpatient E/M visits
- Why Medicare policy introduced a HCPCS alternative for prolonged services
- Which broad types of prolonged service reporting were limited under CMS guidance
- Why payer-specific review remains important for time-based E/M claims
Who Should Read This
- Medical coders
- Medical billers
- Revenue cycle staff
- Compliance teams
- Physician practices
- Outpatient clinic administrators
Codes Discussed
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