In this article, we will provide guidance to the Prolonged Services E/M coding updates for 2024 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 ensured 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.
Reminder that in January 2023 CPT codes 99354 – 99357 for face-to-face prolonged care codes that would have been used with office/outpatient codes or inpatient, observation, or nursing facility were deleted by the American Medical Association (AMA).
Please note the codes in this blog are only valid for commercial Insurance.
- Face-to-Face Guidelines
- Non-face-to-face Guidelines
Prolonged Service Without Direct Patient Contact
These codes are reported for NON-Direct patient contact on a date other than face-to-face date of service. 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.
|Prolonged Serviced Without Direct Patient Contact on Date Other Than the Face-to-Face Evaluation and Management Service
|Prolonged evaluation and management service before and/or after direct patient care; first hour
|Each additional 30 minutes (List seperatly in addition to code for prolonged service)
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. Time spent 60 minutes CPT Code 99358 is our billable code.
Prolong Service Codes 99415, 99416
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.
|Prolonged Clinical Staff Services with Physician or Other Qualified Health Care Professinal Supervision
|CPT Code 99415 Prolonged clinical staff service (the service beyond the highest time in the range of total time of the service) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision, first hour (list separately in addition to code for outpatient evaluation and management services) - (Use 99415 in conjunction with 99202, 899203, 99204, 99205, 99212, 99213, 99214, 99215) -(Do not report 99415 in connection with 99417)
|Each additional 30 minutes (List seperately in additional to code for prolonged service) -(Use 99416 in conjunction with 99415) -(Do not report 99416 in conjunction with 99417)
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. Time spent 60 minutes CPT Code 99415 is our billable code.
- Please Do not 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.
Prolonged Service with or Without Direct Patient Care
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).
When reporting 99417 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.
|Prolonged Service With or Without Direct Patient Contact on the Date of an Evaluation and Management Service
|Prolonged outpatient evaluation and mangement service(s) time with or without direct patient contact betond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time (List seperatly in addition to the code of the outpatient Evaluation and Management service) -(Use 99417 in conjunction with 99205, 99215, 99245, 99345, 99350, 99483) -(Use 994147 in conjunction with 99483, when the total time on the date of the encounter exceeds the typical time of 99483 by 15 minutes or more) -(Do not report 99417 on the same date of service as 90833, 90836, 90838, 99358, 99359, 99415, 99415) -(Do not report 99417 for any time unit less than 15 minutes)
|Prolonged inpatient or observation evaluation and mangement 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 (List seperatly in addition to the code of the outpatient Evaluation and Management service) -(Use 99418 in conjunction with 99223, 99233, 99236, 99255, 99306, 99310) -(Do not report 99418 on the same date of service as 90833, 90836, 90838, 99358, 99359) -(Do not report 99418 for any time unit less than 15 minutes)
Example: Mrs. Jones, a new patient, is seen today for 3 chronic conditions which include diabetes, hypertension, and COPD. After a complete history and physical examination, the provider spent additional time on the following:
- Preparing to see the patient (for example, review of tests) 20 minutes
- Performing a medically appropriate examination and/or evaluation 10 minutes
- Counseling and educating the patient/family/caregiver 25 minutes
- Ordering medications, tests, or procedures 10 minutes
- Documenting clinical information in the electronic or other health record 15 minutes. For a total of 80 minutes our billable codes are 99205 x 99417 for this outpatient visit.
For additional and detailed guidance on billing prolonged services refer to pages 30 – 33 in the 2024 AMA Current Professional Terminology (CPT) book.
Does your practice staff and providers 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.
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