How and when to report prolonged services

By Faith C. M. McNicholas, RHIT, CPC, CPCD, PCS, CDC, Manager, Lead Coding and Reimbursement Strategist, September 1, 2024

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

Prolonged services in dermatology are often necessary for complex cases requiring extended face-to-face and non-face-to-face time with patients and/or family/caregivers. Accurate documentation and reporting of these services are essential for proper reimbursement and compliance with coding and billing regulations.

Previously, dermatologists and/or non-physician clinicians (NPC) reported evaluation and management (E/M) service codes for office or outpatient services (99202-99205 [new patients] and 99212-99215 [established patients]) based on specific ‘time ranges’ assigned to each code to reflect the total time spent on the date of the encounter. These descriptors included a 15-minute buffer before prolonged service codes kicked in and could be reported.

In 2024, the AMA revised these time thresholds associated with certain E/M service codes to clarify the minimum time required to bill an E/M service when the service is reported based on time. This article provides a detailed guide on reporting prolonged services in dermatology, offering practical advice for clinicians to navigate the updated coding requirements effectively.

1. Prolonged service without direct patient contact on a date other than the face-to-face E/M service (CPT^® codes 99358 – 99359)

Dermatologists and/or NPCs may need to continue patient care on dates other than the face-to-face E/M encounter with the patient and/or family/caregiver. Prolonged services for the additional time beyond the usual service duration can be reported using CPT codes 99358 and 99359.

CPT Codes 99358 and 99359 capture prolonged services related to any E/M service on a date other than the face-to-face service, whether time was used to select the level of the face-to-face service or not.

To report these codes, the prolonged services without direct patient contact must be related to other clinician services, including E/M services, on a different date than the face-to-face encounter. These codes can only be used if they relate to ongoing patient management involving a face-to-face encounter, either past or soon-to-be-provided. For example, extensive medical record reviews related to a previous E/M service performed at an earlier date or an upcoming visit qualify.

CPT code 99358 reports the first hour of prolonged service on a given date, even if the time spent by the clinician on that date is not continuous, and can only be used once per date regardless of the place of service. Add-on CPT code 99359 reports each additional 30 minutes beyond the first hour, or for the final 15-30 minutes of prolonged service beyond the first hour on a given date.

Prolonged service of less than 30 minutes on a given date, or less than 15 minutes beyond the first hour, cannot be separately reported. CPT codes 99358 and 99359 also cannot be used for time without direct patient contact reported in other services, such as medical team conferences (99366-99368), interprofessional telephone/Internet/electronic health record consultations (99446, 99447, 99448, 99449, 99451, 99452), or online digital E/M services (99421, 99422, 99423).

Below are the complete code descriptors, along with a table to guide their usage:

2. Prolonged clinical staff services with physician or other qualified health care professional supervision (CPT codes 99415 - 99416)

CPT codes 99415 and 99416 are used for prolonged clinical staff face-to-face time with a patient and/or family/caregiver in an office or outpatient setting, with the dermatologist or NPC providing direct supervision. These codes are reported in addition to the primary E/M services and any other services provided during the same session. Time spent performing separately reported services other than the E/M service is not counted toward the prolonged service time.

CPT code 99415 captures and reports the first hour of prolonged clinical staff service on a given date. This code can only be reported once per date, even if the time is noncontinuous. Services less than 30 minutes in total duration are not separately reported. When face-to-face time is noncontinuous, only the face-to-face time provided to the patient and/or family/caregiver by the clinical staff is reported.

CPT code 99416 captures and reports each additional 30 minutes of prolonged clinical staff service beyond the first hour, including the final 15-30 minutes. Services less than 15 minutes beyond the first hour or the final 30 minutes are not separately reported.

These codes can be reported for up to two simultaneous patients, but the time reported must be devoted exclusively to a single patient. The complete code descriptors and table below provide the typical clinical staff times for office or outpatient primary codes, the range of time beyond the clinical staff time for which CPT code 99415 applies, and the starting point at which 99416 may be reported:

Reporting prolonged clinical staff time

3. Prolonged service with or without direct patient contact on the date of an E/M service (CPT code 99417 - 99418)

CPT code 99417 captures and reports prolonged total time (combined time with and without direct patient contact) provided by clinicians on the date of office or other outpatient services, office consultations, or other outpatient E/M services (e.g., 99205, 99215, 99245, 99345, 99350, 99483). CPT code 99418 reports prolonged total time (i.e., combined time with and without direct patient contact) provided by clinicians on the date of inpatient E/M services (e.g., 99223, 99233, 99236, 99255, 99306, 99310).

These codes are used when the total time exceeds the highest-level primary service by 15 minutes and the service is selected based on time alone. To report a unit of 99417, 99418, 15 minutes of prolonged service time must have been attained. Do not report 99417 or 99418 for any time increment of less than 15 minutes.

When reporting CPT codes 99417 or 99418, the initial time unit of 15 minutes may be added once the time threshold required for 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 have been accumulated beyond 60 minutes (i.e., 75 minutes) on the date of the encounter. For an established patient encounter (99215), do not report 99417 until at least 15 minutes have been accumulated beyond 40 minutes (i.e., 55 minutes) on the date of the encounter.

Time spent performing separately reported services other than the primary E/M service and prolonged E/M service is not counted toward the primary E/M and prolonged services time. For prolonged services on a date other than the date of a face-to-face E/M encounter with the patient and/or family/caregiver, see 99358, 99359.

Below are the complete code descriptors, along with a table to guide their usage:

Examples of initial and multiple units of prolonged service(s)

Additional DermWorld Resources