AMA introduces new prolonged service code for 2021

By Faith C. M. McNicholas, RHIT, CPC, CPCD, PCS, CDC, manager, coding and reimbursement, January 1, 2021

Academy coding staff address important coding topics each month in Derm Coding Consult. Read more Derm Coding Consult articles.

Coding based on time

As previously discussed in the Derm Coding Consult article “E/M coding — What has changed?” time alone can be used as the determining factor for an evaluation and management (E/M) code. Time includes the total time spent by the dermatologist or non-physician clinician (NPC) on the day of the encounter and does not have to be spent on counseling or coordination of care. It includes time spent both face-to-face and non-face-to-face addressing the patient problem.

The American Medical Association (AMA) defines a patient problem as addressed or managed when a presenting problem is evaluated or treated at the encounter by the dermatologist or NPC reporting the service. This includes consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or patient/parent/guardian/surrogate choice.

The table below illustrates time ranges for 2021 E/M service codes.

Prolonged service (PS) code

As part of the 2021 E/M coding changes, the AMA has introduced a new PS code. Dermatologists and NPCs can report this code for the prolonged total time spent with and without direct patient contact on the same day as an office visit. See the code descriptor below.

99417: Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required 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 of total time.

(List separately in addition to codes 99205, 99215 for office or other outpatient evaluation and management services.)

Reporting the new PS code

Code 99417 is only used when the office or other outpatient service has been selected using time as the basis for coding the encounter for private payer patient encounters. It is reported in conjunction with, and only after, the minimum time required to report the highest-level service (i.e., 99205 or 99215) has been exceeded by 15 minutes.

• For new patients, this would be a minimum of 75 minutes.

• For established patients, this would be a minimum of 55 minutes.

• Any time spent with the patient less than 15 minutes in excess of the minimum required time would not qualify to be reported with the prolonged service code 99417.

• Time spent performing separately reported services other than the E/M is not counted toward the time reported for 99205 or 99215 and prolonged service time.

The table below illustrates when Current Procedural Terminology (CPT^®) code 99417 can be reported in conjunction with 99205 or 99215 after the minimum time requirement is met.

Prolonged Service code for Medicare beneficiary encounters

To report prolonged services provided to Medicare beneficiaries, CMS has created HCPCS code G2212 to be used in place AMA CPT code 99417.

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 health care 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.)

(Do not report G2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416.)

(Do not report G2212 for any time unit less than 15 minutes.)

Report G2212 for prolonged services once the maximum required time of the primary E/M service has been surpassed by at least 15 minutes on the date of the encounter. The use of the prolonged service code is reported only if the level of E/M service choice is based on total time.

The table below illustrates how to report prolonged service code for Medicare beneficiary encounters.

* Total time is the sum of all time, including prolonged time, spent by the reporting dermatologist or NPC on the date of service.

PS without direct patient contact on date before and/or after direct care

To report prolonged services on a date other than the date of a face-to-face encounter including office or other outpatient services (99202 – 99215), see 99358 or 99359 Prolonged E/M service before and/or after direct patient care. These codes, 99358 – 99359, may be used when the physician work is more extensive than what has already been captured in the reported E/M code. The PS code may be reported on the same date as an E/M service or on a different date than the primary service to which it is related. It must relate to ongoing patient management from an E/M encounter that has been performed or will occur on a future date.

The PS codes are time-based and can be reported for work involving extensive medical record review, review of diagnostic test results, or other ongoing care management work that does not involve direct patient contact. A reason why the service went above the normal time and effort included in the face-to-face encounter as well as the exact amount of time spent must be documented in the medical record (e.g., 20 minutes in the morning, 25 minutes in the afternoon spent reviewing external medical records and lab results). The code is reported once per day for the total duration of non-face-to-face time spent by the billing physician or NPC on a given date providing prolonged service, even if the time spent by the physician on that date is not continuous regardless of the place. Chart/records review alone, without previous or subsequent direct patient contact, does not qualify to be reported as a prolonged service using codes 99358 or 99359. See question 2 below for a coding example.

Prolonged clinical staff services with dermatologist/NPC supervision

To report E/M services that require prolonged clinical staff time as well as face-to-face services by the dermatologist or NPC, use codes 99415 and 99416. Prolonged clinical staff time should be reported separately in addition to the code for outpatient E/M service. Report 99415 in conjunction with 99416, depending on the total prolonged time spent. See the code descriptors below.

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 service.)

99416: each additional 30 minutes

(List separately in addition to code for prolonged service.)

Code 99415 is used to report the first hour of prolonged clinical staff service time once on a given date, even if the time spent by the clinical staff is not continuous. The maximum face-to-face time described in the primary E/M service code descriptor is used to determine when to begin counting in order to qualify reporting the PS code. Prolonged clinical staff time of less than 30 minutes on a given date is not reported separately because clinical staff time involved is already included in the E/M codes. The service should be provided by clinical staff under the direct supervision of a dermatologist or NPC, and the nature and clinical staff time spent providing the service must be documented in the medical record. See question 3 below for a coding example. The table below illustrates the correct reporting of prolonged services provided by clinical staff with physician supervision.

Question 1: How would you report an encounter where you spend 55 minutes with an established patient?

Answer: As the minimum time required for 99215 (40 minutes), has been exceeded by 15 minutes, this encounter is appropriately reported as:

• 99215

• 99417 x 1unit

Question 2: Two days after seeing and examining an 85-year-old new female patient with history of malignant neoplasms, you receive past medical records from the patient’s previous dermatologist. You spend 30 minutes reviewing the records and communicating with the daughter of the patient. You report 99358 for the prolonged services provided. Is this correct?

Answer: Yes. Prolonged service code 99358 is reported for non-face-to-face services related to a service where face-to-face care has or will occur. This is not an add-on code and can be reported on its own on the day the service is performed.

Question 3: A 16-year-old established patient is seen with an exacerbation of severe acne requiring care coordination and initiation of isotretinoin therapy. You spend 39 minutes addressing the patient problem and clinical staff spend an extra 45 minutes reviewing the iPLEDGE program with the patient and uploading the patient’s data into the iPLEDGE website. How should you report this encounter?

Answer: This encounter is appropriately reported as:

• 99214

• 99415 x 1 unit

For more information, please visit the 2021 E/M resources in the Academy’s Practice Management Center.

Additional DermWorld Resources