Do not report G0316 for any time unit less than 15 minutes. 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 The duration and the content of the evaluation and management code must . 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. Subscribe to receive our FREE monthly newsletter and Everyday Coding Q&A. Learn how to get the most out of your subscription. 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 Providers use Healthcare Common Procedure Coding System (HCPCS) Code G2212 to bill extended time for E/M services. I understand from your article about prolonged services in 2021 that CMS wont pay for prolonged code 99417 and instead developed a HCPCS code for the service. Please choose at least one subscription option. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials. Using it consistently will help practices be reliable in their determinations and provide support in payer audits. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. As with all of these codes, both CPTand HCPCS, the prolonged code may only be added to the highest-level code in the category and then only when time is used to select the service. 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). 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: Warning: you are accessing an information system that may be a U.S. Government information system. The Centers for Medicare & Medicaid Services (CMS) has made several changes to how youll code prolonged services in the last few years. Our expert staff have decadesof combined experience, covering all aspects of coding and reimbursement. The work of the prolonged care may include both face-to-face and non-face-to-face time. When can I bill prolonged services code 99417? Payment Rates for Medicare Physician Services - Evaluation and Management CPT Code; Descriptor; NON-FACILITY (OFFICE) FACILITY . 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 for labor and delivery are not separately reimbursable services. (Do not report G0317 for any time unit less than 15 minutes)). AMA Disclaimer of Warranties and Liabilities 5. Discover how to save hours each week. 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. In the 2021 final rule, CMS argued that you should use +99417 when the total time for visits hits 15 minutes beyond the maximum time range for 99205 (i.e., 89 minutes) and 99215 (i.e., 69 minutes). CPT Code Description for 99417 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. endstream endobj 328 0 obj <. IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK ABOVE ON THE LINK LABELED "I Do Not Accept" AND EXIT FROM THIS COMPUTER SCREEN. HCPCS G2212 (for CMS patients) is reported only in addition to CPT 99205 and 99215. If this is not an edit in the software system you use, speak with your vendor and ask that it be created for Medicare claims only. BY CLICKING ABOVE ON THE LINK LABELED "I Accept", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THESE AGREEMENTS. Both codes describe a prolonged office or other evaluation and management service that requires at least 15 minutes or more of time either with OR without direct patient contact on the date of the primary E/M service (either CPT codes 99205 or 99215). G2212/99417 pedihc Feb 19, 2021 P pedihc Networker Messages 30 Location Lewiston, ME Best answers 0 Feb 19, 2021 #1 Does anyone have any concrete information regarding these additional codes we can use for prolonged E/M Services. CMS is not using allowing practices to report G0316 when the time is 15 more minutes than the CPT typical time. 2. The CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. The AMA assumes no liability for the data contained herein. 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. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Without documentation to support the level as high risk, a prolonged code may not even be applicable, as the level of service must, first and foremost, be a high-level (level 5) service represented by, For more tips, coding scenarios, and resources for your E/M reporting, consider purchasing the. Instead, CMS released HCPCS code G2212 to be used when billing 15 minutes of prolonged services for Medicare, including Medicare Advantage members. MACs may be instructed to focus on specific codes or diagnoses, or even specific extra time units reported. Prolonged services in a nursing facility: CPT code 99418/HCPCS code for Medicare G0317. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. For both, howevever, you can only count time that requires practitioner knowledge and expertise. These valuations were finalized with an effective date of January 1, 2021. Time spent speaking to a licensed professional on the phone for peer-to-peer review would count. For other services (hospital, nursing facility and home and residence services), CPT uses the times stated in the CPT book for the primary code when calculating if a prolonged services code may be added. The AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. G2212 99359 99415 Cross Reference 2021 Current Procedural Terminology (CPT) is copyright 2021 American Medical Association. Check Out This Clinical Scenario * Time must be used to select visit level. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements. MPFS Conversion Factor a Tough Pill for 2023, Unless Congress acts, CF will be significantly cut. The2023 time file is here. Criteria for Using and Submitting CPT Code G2212: Primary E/M service CPT Code 99205 or 99215 is selected based on time and NOT medical decision making and the service was 15 minutes or more Services must be Medically Necessary during the prolonged E/M service. Youll now be allowed to use it to report prolonged services with: 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. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. G0316 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 CPTcodes 99223, 99233, and 99236 for hospital inpatient or observation care evaluation and management services). E/M 2023: Extend Prolonged Service Smarts With New Codes, Extend Prolonged Service Smarts With New Codes, 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, Fortunately, the guidelines for using the code remain the same. 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 ). CMS uses claims data to make future reimbursement and fee schedule decisions, so it is always important that codes such as this make it into the data base. It includes time for some services on the days before or after the face-to-face encounter. This audit tool for modifier 25 will help determine if a separate E/M service should be reported. The latest instructions from CMS on proper use of the G codes: When the practitioner selects a visit level using time, the practitioner may report prolonged office/outpatient E/M visit time using HCPCS add-on code G2212 (Prolonged office/outpatient E/M services). Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare and Medicaid Services (CMS). (Do not report G2212 for any time unit less than 15 minutes)).. Effectively, it is so byzantine that most practices will never be able to bill for them. 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. Recorded April Read More Download Reference Sheet # 99417 Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services), (Use 99417 in conjunction with 99205, 99215, 99245, 99345, 99350, 99483) More details about these office/outpatient E/M changes can be found at CPT Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services . 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. The information below is what was sent to us from our Medicaid program. Please be aware that this information may be stored on a server located in the U.S. Watch this webinar about all these changes. For U.S. Government and other information systems, information accessed through the computer system is confidential and for authorized users only. Both CMS and CPT allow a prolonged service in addition to 99483, assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home. Coding for Evaluation and Management Services: Answers to Common Questions Evaluation and management (E/M) services are at the core of most family medicine practices and represent a category. In the 2021 final rule, CMS argued that you should use +99417 when the total time for visits hits 15 minutes beyond the maximum time range for 99205 (i.e., 89 minutes) and 99215 (i.e., 69 minutes). The CPT Editorial Panel's guidance was that prolonged services could be billed after a visit exceeds the minimum level 5 threshold by 15 minutes. You acknowledge that the AMA holds all copyright, trademark, and other rights in CPT. 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. For 2023, CPT removes the words beyond the minimum required time from the descriptor for +99417, which now reads (Prolonged outpatient 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 (List separately in addition to the code of the outpatient Evaluation and Management service)). 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. Prolonged care services can no longer be used on psychotherapy codes. Youll now be allowed to use it to report prolonged services with: 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. It is always important to properly document, but when a medical necessity audit is looming, be sure to include information that supports the decision making process. For a better experience, please enable JavaScript in your browser before proceeding. 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. 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. This includes items such as CPT codes, CDT codes, ICD-10 and other UB-04 codes. CPT, In the 2021 final rule, CMS argued that you should use, If the patient has private insurance, you would bill 99223 and +99418 as +99418 may be used as soon as the total time [75 minutes] has been exceeded by 15 minutes, according to. 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. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Recently, I discussed a couple of the more commonly encountered types of posterior instrumentation for spinal fusion procedures (posterior instrumentation). No fee schedules, basic unit, relative values or related listings are included in CDT. Lets see what CPT and CMS say. These are added in 15-minute increments in addition to codes 99205 or 99215. See our privacy policy. However, Medicare does not cover 99417 and, instead, created HCPCS code G2212 to report this service. 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. You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. This license will terminate upon notice to you if you violate the terms of this license. Report prolonged cognitive impairment assessment services using G2212, the Medicare-specific code for prolonged office/outpatient services. CMS and CPT still at odds over when to add extra time. 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. 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. Unauthorized or illegal use of the computer system is prohibited and subject to criminal and civil penalties. 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. 99427 Prin care mgmt staff ea addl 1.4 $47.02 NEW CODE NEW CODE NEW CODE 1.03 $34.59 NEW CODE NEW CODE NEW CODE . Look for a description of what activities are included in the time, because this is required when using time to select the office visit codes. If the provider spends 30 additional minutes with the patient, report two units of G2212. Instruction Courses and Skills Transfer Labs, Program Participant and Faculty Guidelines, LEO Continuing Education Recognition Award, What Practices Are Saying About the Registry, Provider Enrollment, Chain and Ownership System (PECOS), Subspecialty/Specialized Interest Society Directory, Subspecialty/Specialized Interest Society Meetings, Minority Ophthalmology Mentoring Campaign, Global Programs and Resources for National Societies, RetinaBiosimilars, Dual Inhibitors, and Coding for New Drugs, Boost Your MIPS Score: Pitfalls to Avoid, Tips to Follow, Cataract Comanagement ComplianceCMS Outreach Prompts Internal Reviews, MIPS 2023Quality Measure Benchmark Summaries, MIPS 2023Key Dates for Performance Year 2023, 2023 Fundamentals of Ophthalmic Coding Course (Live Virtual), 2023 Fundamentals of Ophthalmic Coding Course (Recording), Fundamentals of Ophthalmic Coding Course (Virtual), 2023 IRIS Registry (Intelligent Research in Sight) Preparation Kit, 2023 Codequest Virtual - Multistate (Recorded March 28), 2023 Coding Coach: Complete Ophthalmic Coding Reference, 2023 CPT: Complete Pocket Ophthalmic Reference, 2023 Retina Coding: Complete Reference Guide, 2023 Coding Assistant: Cataract and Anterior Segment, 2023 Coding Assistant: Pediatrics/Strabismus, Ophthalmic Medical Assisting: An Independent Study Course, Essentials of Ophthalmic Nursing kit RVSD (V1-V4), 2023 ICD-10-CM for Ophthalmology: The Complete Reference, 2022-2023 Basic and Clinical Science Course, Complete Print Set, 2022-2023 Basic and Clinical Science Course, Complete eBook Set, 2022-2023 Basic and Clinical Science Course, Complete Print and eBook Set, 2022-2023 Basic and Clinical Science Course, Residency Print Set, 2022-2023 Basic and Clinical Science Course, Residency eBook Set, International Society of Refractive Surgery. 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. 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. 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 Sign up for our monthly newsletter to download the reference sheet. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. 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. Applications are available at the AMA Web site, https://www.ama-assn.org. Otherwise, the actual billing codes for E/M services remain the same. Coding for prolonged services is complicated by the fact CPTand CMS use different codes and different time thresholds. Your email address will not be published. The sole responsibility for the software, including any CDT and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. Note: The information obtained from this Noridian website application is as current as possible. Effectively, all prolonged services coding will need to be done by coders. Helps here: This article will discuss all the new codes, and coding conventions, that are part of prolonged services coding in 2023. Note that CMS allows the practitioner to include time spent three days before the date of the visit and seven days after. The information below is what was sent to us from our Medicaid program. CMS use the time in the. Privacy Policy, Compliance issues in ICD-10 coding for risk based contracts and HCCs, CPT Coding for Bronchoscopy Procedures | Webinar, CMS Split/Shared Services Rules | Reference Sheet, screening and counseling for behavioral conditions. Not only are there different codes depending on payer, the time thresholds are different. The Centers for [], To avoid confusion over code choice for your Medicare and private payer patients, and to [], Count This Instead of Shots for Accurate TPI Tally, Heres why the number of overall shots is irrelevant to your code choice. 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 The AMA does not directly or indirectly practice medicine or dispense medical services. 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. Fortunately, the guidelines for using the code remain the same. Time is calculated ONLY for time spent on the day of the E/M encounter (not the day before or days following, even if additional services are provided on those days. The disagreement stems from whether to start counting the 15 minutes of prolonged care at the minimum time threshold for the code or the maximum time threshold. Thank you for choosing Find-A-Code, please Sign In to remove ads. And, there is not a replacement code for this service for Medicare. 327 0 obj <> endobj To align TRICARE policy with Medicare policy, providers should use HCPCS code G2212 (each additional 15 minutes, but not less than 15 minutes), when billing for prolonged services in addition to Current Procedural Terminology (CPT) codes 99205, 99215 or 99483.