Payers constantly change their reimbursement policies which affect medical billing codes. If your practice doesn’t stay up to date with these changes, your reimbursements could:
- Get delayed,
- Get denied,
- Or only partially paid.
Just in 2022 alone, according to the American Medical Association (AMA), 405 Current Procedure Terminology (CPT) code changes were made.
In this article, we will provide guidance to the Prolonged Services E/M code changes for 2023 to avoid denials and rejections and prevent subsequent revenue leakage.
Stay Tuned for Medicare-approved Codes to report Prolonged Services…. We will be publishing a follow-up article focused on this topic soon.
What are Prolonged Service E/M Codes?
Additional care (time spent caring for a patient beyond the E/M codes approved time) provided after an evaluation and management (E/M) service is referred to as prolonged service. Physicians and other qualified clinical staff spend additional time on patient care beyond the highest level of the E/M code time range. This can happen in inpatient, outpatient, or in facility settings.
Although many EHR systems are automatically updated to reflect coding changes, some may lag or not update at all. You are responsible for ensuring that you bill using the correct codes to provide efficient, timeous payments for services rendered.
To get a better grasp on the prolonged service E/M code changes, we decided to split up the changes so that the information could be digested with less effort.
Please note the codes in this blog are only valid for commercial Insurance
- Face-to-Face Guidelines
- Non-face-to-face Guidelines
Face-to-Face Coding Guidelines
Deletion of Prolonged Services E/M codes 99354-99357:
The American Medical Association (AMA) has deleted prolonged codes 99354, 99355, 99356, and 99357 (as of January 2023). CPT code range 99354 – 99357 were face-to-face prolonged care codes that could be used with office/outpatient codes or inpatient, observation, or nursing facility.
See “Codes 99415, 99416” section below for more information.
Codes 99415, 99416
Note: These codes can be used in lieu of the deleted codes 99354-99357.
These codes are used when an evaluation and management (E/M) service is provided in the office or outpatient setting that involves prolonged clinical staff face-to-face time with the patient and/or family/caregiver.
The physician or other qualified health care professional is present to provide direct supervision of the clinical staff. This service is reported in addition to the designated E/M services and any other services provided at the same session as E/M services.
Codes 99415, and 99416 are used to report the total duration of face-to-face time with the patient and/or family/caregiver spent by clinical staff on a given date providing prolonged service in the office or other outpatient setting, even if the time spent by the clinical staff on that date is not continuous.
For example, if the clinical staff/ provider spent time in updated clinical notes, reviewing results for a patient before the face-to-face visit on the same day followed by the E/M visit. The clinician can bill prolonged hours for these non-continuous tasks performed for patient care.
Please Don’t include any administrative time spent on patient visits, like calling insurance to get authorization.
Prolonged service of fewer than 30 minutes total duration on a given date is not separately reported.
Please use this code starting 31 minutes of extra time after the maximum time is exhausted for the highest level of E/M code.
Report the first hour of prolonged clinical staff service on a given date. For example, a clinician should use 99415 if the therapy session goes beyond 90 minutes. 99415 should be used to report a time range of 91 minutes to 150 minutes.
Code 99415 should be used only once per date, even if the time spent by the clinical staff is not continuous on that date.
Code 99416 is used to report each additional 30 minutes of prolonged clinical staff service beyond the first hour. Code 99416 may also be used to report the final 15-30 minutes of prolonged service on a given date. Prolonged service of fewer than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.
Non-Face-to-Face Coding Guidelines
E/M codes 99358 and 99359
These codes are reported for NON-Direct patient contact on a date other than face-to-face DOS. These codes are used when a prolonged service is provided on a date other than the date of a face-to-face evaluation and management encounter with the patient and/or family/caregiver.
Codes 99358 and 99359 may be reported for prolonged services in relation to any evaluation and management service on a date other than the face-to-face service.
This service is to be reported in relation to other physicians or other qualified healthcare professional services, including evaluation and management services at any level, on a date other than the face-to-face service to which it is related. Prolonged service without direct patient contact may only be reported when it occurs on a date other than the date of the evaluation and management service.
Code 99358 is used to report the first hour of prolonged service on a given date, regardless of the place of service. It should be used only once per date.
For example, extensive record review may relate to a previous evaluation and management service performed at an earlier date. However, it must relate to a service or patient in which (face-to-face) patient care has occurred or will occur and relate to ongoing patient management.
CPT Codes 99417
Code 99417 is used to report prolonged total time (i.e., combined time with and without direct patient contact) provided by the physician or other qualified health care professional on the date of office or other outpatient services, office consultation, or other outpatient evaluation and management services (i.e., 99205, 99215, 99245, 99345, 99350, 99483).
Code 993X0 is used to report prolonged total time (i.e., combined time with and without direct patient contact) provided by the physician or other qualified health care professional on the date of an inpatient evaluation and management service (i.e., 99223, 99233, 99236, 99255, 99306, 99310).
The prolonged total time is 15 minutes beyond the time required to report the highest-level primary service. Codes 99417 and 993X0 are only used when the primary service has been selected using time alone as the basis and only after the time required to report the highest-level service has been exceeded by 15 minutes.
To report a unit of 99417, 993X0, 15 minutes of time must have been attained. Do not report 99417, 993X0 for any time increment of fewer than 15 minutes.
When reporting 99417 and 993X0, the initial time unit of 15 minutes should be added once the time in the primary E/M code has been surpassed by 15 minutes. For example, to report the initial unit of 99417 for a new patient encounter (99205), do not report 99417 until at least 15 minutes of time has been accumulated beyond 60 minutes (i.e., 75 minutes) on the date of the encounter.
For an established patient encounter (99215), do not report 99417 until at least 15 minutes of time has been accumulated beyond 40 minutes (i.e., 55 minutes) on the date of the encounter.
How to stay on top of medical billing changes
405 Current Procedure Terminology (CPT) code changes in one year…
405 reasons to ask yourself if your billing team is proactive and staying on top of their game….
Do they have the capacity to free themselves from their daily workload to monitor and report on their billing practices to ensure that your practice is not leaving money on the table?
Neolytix has been fortifying practice revenue cycles for over 10 years. We have dedicated experts on our team, constantly scanning and monitoring the environment not only to stay on par with coding changes but also with compliance-related issues, emerging trends, and best-practice processes arising within the medical industry.
Schedule a free, no-obligation consultation with us. Let’s see how we can bring the best of medical billing to your practice.
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