2021 Changes: Get $20 for New Prolonged Service Codes

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2021 Changes: Get $20 for New Prolonged Service Codes

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2021 prolonged services changes

2021 prolonged services codes help you capture additional reimbursement for the extra time you spend with time-intensive patients, but you must meet all the requirements to correctly bill the added minutes, or you’ll face denials and be forced to hand over your much-needed pay.

IMPORTANT: CMS assigned values to a new Medicare only prolonged service code – and AMA created a different 2021 prolonged service code. Both of these codes – G2212 and 99417 – have unique guidelines you must quickly master in 2021 to not leave dollars on the table. Here are the codes’ official descriptions:

  • 99417Prolonged 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
  • 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) which pays approximately $20 on the 2021 Medicare Physician Fee Schedule (G2212 has 0.61 work relative value units * 2021 conversion factor of $32.4085 = $19.76)

Add Direct Plus Certain Indirect Minutes

When counting total time, CMS and CPT agree that you can add face-to-face patient time as well as some non face-to-face time. For patient-provider face-to-face time, include all the time spent with the patient on the same calendar day as the patient visit. You should also count time without direct patient contact when that non-face-to-face time requires provider expertise. Some examples include but are not limited to:

  • Reviewing tests or charts
  • Ordering tests, procedures, or drugs
  • Documenting in the patient health record
  • Communicating with the patient’s caregivers
  • Communicating with other providers

Here are a few other guidelines to keep in mind when counting total time for 99417:

  • Include only the physician or other qualified healthcare provider’s time. Do not include clinical or non-clinical staff time
  • If you perform services during the calendar day that you’re billing with a unique CPT code, do not count the time spent providing those services towards total time — that’s double dipping
  • You may use 99417 only when you are billing 99205 or 99215 based on time. Do not use 99417 when you are selecting a level-five visit based on medical decision making (MDM)

Bill New Prolonged Service Code Only in Addition to 99205 or 99215

CMS and AMA also both require that you bill 99417 only in addition to a level five E/M codes 99205 and 99215 — when the total time of the visit exceeds that of a level-five visit. But when it comes to defining when the excess time begins, Medicare and CPT part ways.

CPT 2021 assigns 60-74 minutes to 99205 for a new patient office visit and 40-54 minutes to 99215 for an established patient level five visit. When billing the highest-level office visit based on time, you’d start using 99417 at 75 minutes for a new patient and at 55 minutes for an established patient; add-on code 99417 represents each additional 1-14 minutes of prolonged service time. Here are how many units you’d bill per CPT for various established patient visits that exceed 54 minutes of time:

  • 55-69 minutes: 99215, 99417
  • 70-84 minutes: 99215, 99417 x 2
  • 85-99 minutes: 99215, 99417 x 3

In contrast, CMS requires you to tally an additional 15 minutes of time before you bill its prolonged service code G2212. When billing the highest-level office visit based on time, you’d start using G2212 at 89 minutes for a new patient and at 69 minutes for an established patient; add-on code G2212 represents each additional 1-14 minutes of prolonged service time after you’ve provided 15 minutes of care beyond 99205 or 99215. Here are how many units you’d bill to a Medicare contractor for various established patient visits that exceed 54 minutes of time:

  • 89-103 minutes: 99215, G2212
  • 104-118 minutes: 99215, G2212 x 2
  • 119-23 minutes: 99215, G2212 x 3

How this affects your daily billing: You will to track different times when coding 99417 — one when billing Medicare patients, and one when billing private-pay patients. Check with your major payers to determine exactly how they want you to count extended time when billing prolonged services.

99417 replaces other prolonged care codes.  

Starting in 2021, you should no longer report prolonged service codes 99354, 99355, 99358, and 99359 in addition to a level-five office visit. That’s because 99417 replaces 99354 and 99355 (face-to-face prolonged care), and 99358 and 99359 (non-face-to-face prolonged care) for prolonged services with 99205 or 99215.

However, you would still use prolonged service codes 99354/99355 and 99358/99359 for time spent beyond the usual service included in:

  • 90837 (Individual outpatient psychotherapy services, 53+minutes)
  • 90847 (Family psychotherapy with the patient present, 50 minutes)
  • 9924199245 (Office or other outpatient consultation services)
  • 9932499327 (Domiciliary, rest home, or custodial care visit)
  • 9934199350 (Home services)
  • 99483 (Cognitive assessment and care plan)

Apply the following guidelines:

  • Use 99354 for the first hour of face-to-face prolonged service time
  • Use 99355 for each additional 30 minutes of face-to-face prolonged service beyond the first hour
  • Use 99358 for the first hour of non-face-to-face prolonged service time
  • Use 99359 for each additional 30 minutes of non-face-to-face prolonged service beyond the first hour

Related Online Training Resources

EM coding COVID-19-TESTING-CODING-275 2020-CPT-Code-Changes-275
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Master Massive E/M Coding Changes (99201-99215) by Jan. 1 Deadline
Get Paid $25/ea. for New Patient COVID-19 Testing With 99211 Master Provider Enrollment Basics to Keep Your Revenue Flowing
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