(Do not report G0317 for any time unit less than 15 minutes)). Internal/External Audits: When trying to determine whether or not the level of service qualified as a level five (5) service (high risk), an auditor would be looking for key words such as complicated, severe, risk of death, organ failure, or dysfunction. For Medicare patients, there is a HCPCS code. 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. You cant report the new add on code on the same day as psychotherapy, non-face-to-face prolonged care codes 99358, 99359 or staff prolonged care codes. This makes no sense. PDF Payment Policy | Prolonged Physician Services - BCBSRI 2. Some of the Provider information contained on the Noridian Medicare web site is copyrighted by the American Medical Association, the American Dental Association, and/or the American Hospital Association. And wish I had started looking there in the first place! The total time must be documented. Coding for prolonged services: CPT and HCPCS codes - CodingIntel CPT codes 99417 and 99418 are not accepted for processing for Commercial or Medicare Advantage plans. Academy coding advice is based on current information. Bone Up on +99417 Definition The AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. CPT codes 99358, 99359 or 99417 are not valid for Medicare with status indicator "I" on the physician fee schedule. Example: An established patient, high risk E/M service took a total of 68 minutes. In other words, 1-14 additional minutes of E/M service does not warrant a unit of G2212. Required fields are marked *. No charge. (2021, February 3). For the 2023 final rule, CMS has taken a similar view of +99418, believing that the billing instructions for the code would lead to administrative complexity, potentially duplicative payments, and limit our ability to determine how much time was spent with the patient using claims data. In its place, they have introduced three more G codes: First, consult the Clip & Save guide elsewhere in this article, then determine how you would code for inpatient care lasting 95 minutes for a patient who has just been admitted to the hospital. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. Prolonged services codes are add-on codes to E/M services. Payment Rates for Medicare Physician Services - Evaluation and Management CPT Code; Descriptor; NON-FACILITY (OFFICE) FACILITY . What about the extra 15 min from 54-69 minutes? associate partner at Pinnacle Enterprise Risk Consulting Services, Charlotte, North Carolina. You acknowledge that the AMA holds all copyright, trademark, and other rights in CPT. The definition of 99417 is above. CMS and CPT still at odds over when to add extra time. This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. I dont know what edits individual MACs are setting up for these codes, but I recommend that you continue to submit all add-on codes on the claim with the primary code, following CPT rules and CMS guidance. And, CPT simply states to use the code when the total time of the highest-level service (selected based on time) is 15 minutes more than the time described in the CPT book. CMS does not recognize 99417 for Medicare Advantage members. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. CMS does not recognize consult codes. Otherwise, the actual billing codes for E/M services remain the same. The duration and the content of the evaluation and management code must . Warning: you are accessing an information system that may be a U.S. Government information system. CPT allows you to add the 15 minutes to the lower time threshold in the range, and CMS requires you to add the 15 minutes to the higher time threshold in the range. You can only use codes 99417 A colleague said she was getting conflicting opinions about this. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. The 2021 Medicare Payment and CPT Coding Update | AAFP HCPCS code 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 CMS: How to properly report the E/M add-on G codes See the CMS Table 24 below. *IMPORTANT NOTE: The new add-on prolonged services codes G2212 and 99417 will NOT BE EFFECTIVE UNTIL 2021; do not use these new codes for services prior to January 1, 2021. The AMA assumes no liability for the data contained herein. 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 The work of the prolonged care may include both face-to-face and non-face-to-face time. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. G2212 effective January 1st, 2021. We do not expect reporting of HCPCS code G2211 when the office/outpatient E/M visit is reported with payment modifiers such as a modifier -24, -25 or -53. This warning banner provides privacy and security notices consistent with applicable federal laws, directives, and other federal guidance for accessing this Government system, which includes all devices/storage media attached to this system. Whether its the changes CMS implemented to prolonged service coding with the 2023 final rule, or the different ways Medicare and payers who follow CPT guidelines code for prolonged services, things are getting tricky when trying to report these services. However, for a Medicare patient, you would not be able to bill 99223 with G0316 in this situation as even though 99223 may have been exceeded by 15 minutes, the codes descriptor tells you not to report G0316 for any time unit less than 15 minutes. In this case, the unit of the prolonged service time, 5 minutes, is less than 15 minutes, so you will only bill Medicare for the 99223 service. o New CPT code 99417 can be reported for each 15 minutes of prol onged care performed on the same day beyond the maximum time listed for E/M codes 99205 and 99215. I think the question was prompted by the fact that for certain services provided by practitioners in a facility the add-on prolonged care codes includes time the days before or in the days after the face-to-face encounter. Prolonged services codes may only be added to the highest-level code in the category. Billing for Prolonged Services - tricare-west.com The entire 15 minutes must be done, in order to add on this new, prolonged services code. CMS Disclaimer AMA Disclaimer of Warranties and Liabilities Prolonged services in a nursing facility: CPT code 99418/HCPCS code for Medicare G0317. G0316 (Prolonged hospital inpatient or observation care evaluation and management service(s) beyond the total time for the primary service each additional 15 minutes ) for prolonged inpatient or observation E/M service codes 99223, 99233, and 99236 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 (list separately in addition to CPT codes 99223, 99233, and 99236 for hospital inpatient or observation care evaluation and management services). You must log in or register to reply here. You may also contact AHA at ub04@healthforum.com. It may not be reported with psychotherapy or non-face to face prolonged care codes, or discharge services 99238, 99239, 99315, 99316. The CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. Start and end times, or total time, of the visit should be documented in the medical record along with the date of service. For 2023, CPT also deletes prolonged service codes +99354 and +99355. At any time, and for any lawful Government purpose, the government may monitor, record, and audit your system usage and/or intercept, search and seize any communication or data transiting or stored on this system. %PDF-1.6 % According to CPT and HCPCS, prolonged service codes 99354-99357, 99359, 99415-99416, 99437, 99439 and G0513-G0514, G2212 are considered add-on codes and should not be reported without the appropriate primary code. According to CMS: Trying to become comfortable with new codes is always a challenge and these added requirements are a bit confusing. Medical coding resources for physicians and their staff. CMS is allowing time on after the date of the encounter to be used for prolonged services in relation to hospital services. In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. Split/shared services Read More All content on CodingIntel is copyright protected. CMS created HCPCS codes when billing Medicare for prolonged Evaluation and Management (E/M) services which exceeds the maximum time for the highest level (99205, 99215, 99223, etc.) CMS uses highest value in time range for CPT codes. Do not report G0317 for any time unit less than 15 minutes. When the time of the reporting practitioner is used to select the office/outpatient E/M visit level, HCPCS code G2212 could be reported when the maximum time for the highest level (level five) office/outpatient E/M visit (99205 or 99215) is exceeded by at least 15 minutes on the date of the service. (G2212) Do you have any recommendations about how to manage this in the office? The source of this chart is CMSs 2023 Final Rule. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. Update: On Dec. 21, Congress delayed implementation of the primary care add-on code, G2211, for three years as part of the 2020 Year End Funding Bill and COVID-19 Emergency Funding, and it. CMS is finalizing the application of HCPCS code 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, To obtain comprehensive knowledge about the UB-04 codes, the Official UB-04 Data Specification Manual is available for purchase on the American Hospital Association Online Store. Making copies or utilizing the content of the UB-04 Manual or UB-04 Data File, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual / Data File or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. Its the place for leaders to [], March 29, 2023 / By Garri Garrison, Kelli Christman, I sat down with the 3M Health Information Systems Division President Garri Garrison to talk about the upcoming HIMSS show in Chicago and what you can expect at the 3M [], Barbara Aubry, RN, CPC, CPMA, AAPC Fellow, CHCQM, FABQAURP is a senior regulatory analyst for 3M Health Information Systems. Same-Day Admission/Discharge (99236), IP/Obs. For more about Betsy visit www.betsynicoletti.com. Please choose at least one topic center option. 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. This license will terminate upon notice to you if you violate the terms of this license. A practitioner may include these activities in their time, when using time to select an E/M service: Per CPT, use 99417 for office visits, outpatient consults, home and residence services and cognitive assessment planning. You are using an out of date browser. You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. Use CPT code times on the date of service only, Use time three days before visit, date of visit and 7 days after visit. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. There are different CPT and HCPCS codes that describe the same prolonged care services. coding guidance prior to the submission of claims for reimbursement of covered services. Our expert staff have decadesof combined experience, covering all aspects of coding and reimbursement. So for an established patient can we not bill for a prolonged service unless it is 69 min or longer? Recorded April Read More Download Reference Sheet Does anyone have any concrete information regarding these additional codes we can use for prolonged E/M Services. CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. 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. Split (or Shared) Visits According to the AMA, the E/M work expense value already takes into consideration time spent caring for the patient (e.g., phone calls, prescriptions, questions, calling patient with test results) for the three days prior to and seven days following the actual E/M service, so if time spent performing these services was counted in addition to the time spent on the actual date of the encounter, this would be considered double dipping. This reminds me a bit of the medical necessity audits for one-night stays and all the challenges of that time. CPT/HCPCS Codes Descriptor . Yes. Please be aware that this information may be stored on a server located in the U.S. HCPCS code G2211 may be reported with any visit level. Billing For Dementia Care 2021 - CAPC (Do not report 99418 on the same date of service as 90833, 90836, 90838, 99358, 99359) Table 20 below provides a summary of the codes and work RVUs finalized in the CY 2020 MPFS final To avoid potential confusion with CPT guidelines, CMS created a new prolonged service code, recognized by Medicare and payers following Medicare payment rules, to take its place: 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 ). Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare and Medicaid Services (CMS). Medical Necessity The provider documented the service, including the severity of the patient's condition and decision to admit to the hospital based on EKGand chest x-ray findings positive for pneumonia. It doesnt follow CPT typical times, or CPT prolonged services rules. Now, they are only applicable on the highest level of service, but there are two sets of codes and the time thresholds are different for each one. All rights reserved. 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 (List Reasonable coders and practitioners can and do disagree about when a separate E/M service is warranted on the day of a minor procedure. CMS newly created HCPCS code G2212 is to be used for billing Medicare for prolonged Evaluation and Management (E/M) services which exceed the maximum time for a level five (99205, 99215) office/outpatient E/M visit by at least 15 minutes on the date of service. G2212 is a valid 2023 HCPCS code for 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 Register for our on-demand E/M education series. Last Updated Wed, 22 Mar 2023 12:22:35 +0000. And, Medicare has given them a status code of invalid, which means they wont pay for it. Health information management (HIM) professionals are [], Each year 3M brings together some of the brightest minds in health care, clinical documentation and health information management at our annual 3M CES. CPT also deletes prolonged service codes +99356 and +99357 for 2023 and introduces another code: +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 ), which had been previously give the placeholder code of 993X0. LICENSE FOR USE OF "PHYSICIANS' CURRENT PROCEDURAL TERMINOLOGY", (CPT) The full 15 minutes is required and time must have been used to select the level of service. Revenue Code Descriptor . Medicare and the AMA do not agree on how to define the time factors of "prolonged service". Ok, so I found this on another websitethis seems to follow what you are saying, so this would be correct? Remember that these codes may only be reported with 99205 or 99215 . endstream endobj 328 0 obj <. This blog focuses on types of anterior instrumentation for spinal [], Its Health Information Professionals Week and we want to take the time to thank all those who keep health information accurate, secure and accessible. 3. David B. Glasser, MDSecretary, Federal Affairs, Michael X. Repka, MD, MBAMedical Director, Government Affairs, Joy Woodke, COE, OCS, OCSRDirector, Coding and Reimbursement, Matthew Baugh, MHA, COT, OCS, OCSRManager, Coding and ReimbursementHeather H. Dunn, COA, OCS, OCSRManager, Coding and Reimbursement. Use time one day before visit, date of visit and three days after visit, IP/Obs. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. PDF REIMBURSEMENT POLICY Prolonged Services - Blue Cross MN CPT instructs you to use +99417 when service times for 99205 (Office or other outpatient visit for the evaluation and management of a new patient 60-74 minutes of total time is spent on the date of the encounter) or 99215 (Office or other outpatient visit for the evaluation and management of an established patient 40-54 minutes of total time is spent on the date of the encounter) go 15 minutes beyond the minimum for the 99205/99215 time ranges 75 minutes for a new patient visit and 55 for an established patient and additional units for every 15 minutes beyond those times. G2212 effective January 1st, 2021. For Medicare, medical necessity is the overarching criteria, in addition to component scoring, used to determine the level of E/M service. G2212 is to be used for billing the MPFS instead of CPT code 99358, 99359 or 99417, with the following descriptor: "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 PDF Final Rule Summary - American Society for Radiation Oncology Retrieved from https://www.findacode.com/articles/how-to-properly-report-prolonged-services-using-99417-or-g2212-36784.html. There are two codes for office based prolonged time: G2212 for Medicare Part B patients and 99417 for payers that don't follow CMS. When a [], Allergic Arthritis Dx Nothing to Sneeze At, Question:Encounter notes indicate that a patient suffered from allergic arthritis, R ankle. Is this a [], Know Purpose of Shoulder Arthroscopy Before Coding, Question:Encounter notes indicate that the provider performed a level-four office evaluation and management (E/M) service [], Get Off on Right Foot With F/T Modifier Coding, Question:Im relatively new to orthopedic coding, so a couple of the modifiers Im familiarizing myself [], Copyright 2023. CMS prolonged service guidelines are different from the American Medical Association (AMA). 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 (list separately in addition to cpt codes 99205, 99215 . If the provider spends 30 additional minutes with the patient, report two units of G2212. 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 separately in addition to CPT codes 99306, 99310 for nursing facility evaluation and management services). Medicare has assigned a status indicator of invalid to code 99417, and developed a HCPCS code to replace it, G2212, If using either code, only report it with codes 99205 and 99215, use only clinician time, and use it only when time is used to select the code, Use for time spent face-to-face and in non-face-to-face activities, preparing to see the patient (eg, review of tests), obtaining and/or reviewing separately obtained history, performing a medically appropriate examination and/or evaluation, counseling and educating the patient/family/caregiver, ordering medications, tests, or procedures, referring and communicating with other health care professionals (when not separately reported), documenting clinical information in the electronic or other health record, independently interpreting results (not separately reported) and communicating results to the, care coordination (not separately reported). (Do not report G0317 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99418,). It also included an extensive discussion with the patient and his sister about treatment options and recovery time, if he decides on surgery.. The following codes are covered and separately reimbursed when documentation requirements are met: G2212Prolonged 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 CPT codes 99417 and 99418 will be denied with one of the following: Denial explanation code: 53B This procedure code is not accepted for processing by Moda Health for HCPCS code 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. All rights reserved. It appears CMS may be using this add-on code to document care that includes use of care teams including use of community resources to meet social determinants of health, such as access to reliable transportation. MPFS Conversion Factor a Tough Pill for 2023, Unless Congress acts, CF will be significantly cut. No fee schedules, basic unit, relative values or related listings are included in CDT. The medical record must be appropriately and sufficiently documented by the physician or qualified Non-Physician Practitioner (NPP) to show that the physician or qualified NPP. Medicare Administrative Contractors (MACs) will process claims per the Internet Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 12, section 30.6.15. Therefore, you have no reasonable expectation of privacy. CPT allows with consults. Practitioners may report this code for qualifying visits furnished on or after January 1, 2021, although we assigned a PFS payment status indicator of B (Bundled) until 2024. 327 0 obj <> endobj Practitioners should not report prolonged office/outpatient E/M visit time using CPT codes 99354 and 99355 (Prolonged service with direct patient contact), 99358 and 99359 (Prolonged service without direct patient contact), 99415 and 99416 (Prolonged clinical staff services), or 99417 (Prolonged office/outpatient E/M services with or without direct patient contact), HCPCS code 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 (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services). 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