Everybody makes mistakes, but when it’s CMS creating the error, it can create ripple effects through your practice. Hopefully, the agency’s latest mistake provides your practice with a benefit rather than a headache. At issue is the time threshold that must be met to report code G0316, which represents prolonged inpatient/observation care for Medicare patients.
Check out what CMS says about the time guidelines for G0316, and how to calculate when you should report this code.
Look to 90 Minutes as Your Guide for Initial Visits
When CMS first debuted G0316, the code was meant to describe prolonged inpatient E/M services, with the descriptor as follows:
- 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 CPT codes 99223, 99233, and 99236 for hospital inpatient or observation care evaluation and management services). (Do not report G0316 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99418, 99415, 99416). (Do not report G0316 for any time unit less than 15 minutes))
The agency published directions on using this code in the 2023 Fee Schedule Final Rule, which stated that “a practitioner could bill G0316 for base code CPT code 99223 when 105 minutes is reached for an initial visit on the date of encounter.”
Some coders wondered how CMS arrived at the number 105, since it didn’t line up with the time thresholds stated elsewhere.
CMS later recalculated, issuing a correction on March 15 noting that this number should instead refer to 90 minutes, not 105.
Therefore, if you see a patient for 90 minutes during initial hospital care, you can report 99223 and G0316.
Count to 65 Minutes for Subsequent Visits
The time threshold was also incorrect for G0316 when it came to subsequent inpatient or observation visits, which previously indicated that this code could be billed once the 15-minute increment passed following 80 minutes with 99233.
The correction indicates that after 65 minutes is reached when billing 99233, you can start reporting G0316, thus changing the 80 minutes to 65. Therefore, if you see a patient for a 65-minute subsequent hospital care visit, you can report 99233 and G0316.
For Same-Day Admit/Discharge, Tally 110 Minutes
CMS also outlined an error for G0316 when it comes to tallying time for same-day admission and discharges. The Fee Schedule originally said you can report G0316 after 125 minutes of time had passed with code 99236. In reality, however, that number should be 110 minutes.
So if you spend 110 minutes with a patient for an admission and discharge visit, you can report 99236 with one unit of G0316 for Medicare patients.
Chart: Putting It All Together
To easily navigate the timelines for reporting G0316, check out this table.
Seeking more detail about what the 2023 Physician Fee Schedule includes? Let expert Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, help! During her 90-minute online training event, “Master 2023 E/M Coding Changes,” Kim will walk you through the details you need to know so you can code correctly this year. Sign up today!
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