Establishment of Prolonged Services E/M code 993X0 and guidelines: The AMA is
developing a new prolonged care code, which is not released in its recent update. The
placeholder code that the AMA is using is
993X0 for additional 15-minute increments of
time with or without patient contact to be used with hospital codes 99223, 99233, and
99236, and consult code 99255, and nursing facility codes 99306 and 99310.
The prolonged services codes may now only be used with the highest level code in the
category or subcategory.
Also note that in the Medicare proposed rule, they are
developing additional HCPCS codes for prolonged care, and will not recognize the CPT
codes.
Coding prolonged services in the hospital:
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 (List separately in addition to the code of the inpatient and observation Evaluation and Management service)
(Use in 99418 conjunction with 99223, 99233, 99236, 99255, 99306, 99310)
(Do not report 99418 on the same date of service as 90833, 90836, 90838, 99358, 99359)
(Do not report 99418 for any time unit less than 15 minutes)
99418 may be used on the highest-level initial and subsequent inpatient and observation codes, inpatient consult, and initial and subsequent nursing facility services. It may not be reported with psychotherapy or non-face to face prolonged care codes, or discharge services 99238, 99239, 99315, 99316. It may not be used with Emergency Department codes. The full 15 minutes is required and time must have been used to select the level of service.
As expected, CMS is not recognizing the new CPT® code 99418. For Medicare patients, there is a HCPCS code. And, as expected, the time thresholds are unique. Really unique. CMS is not using the published typical times for the codes, but the time in the CMS time file, developed by the RUC.
Prolonged services codes are defined by CPT and CMS using different codes, and requiring different time thresholds to use the codes.
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Establishment of Prolonged Services E/M code 993X0 and guidelines
Codes 99417, 993X0 are only used when the primary service has been selected using time alone
as the basis and only after the time required to report the highest-level service has been exceeded
by 15 minutes. To report a unit of 99417, 993X0, 15 minutes of time must have been attained.
Do not report 99417, 993X0 for any time increment of less than 15 minutes.
When reporting 99417, 993X0, the initial time unit of 15 minutes should be added once the time
in 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 of
time has been accumulated beyond 60 minutes (ie, 75 minutes) on the date of the encounter. For
an established patient encounter (99215), do not report 99417 until at least 15 minutes of time
has been accumulated beyond 40 minutes (ie, 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 evaluation and management
encounter with the patient and/or family/caregiver, see 99358, 99359. For E/M services that
require prolonged clinical staff time and may include face-to-face services by the physician or
other qualified health care professional, see 99415, 99416. Do not report 99417, 993X0 in
conjunction with 99358, 99359, 99415, 99416.◄
#★✚●993X0
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 (List separately in addition to the
code of the inpatient and observation Evaluation and Management
service)
►(Use 993X0 in conjunction with 99223, 99233, 99236, 99255, 99306,
99310)◄
Remember G Codes for Medicare Patient Prolonged Services
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). 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 …).
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:
- G0316 (Prolonged hospital inpatient or observation care evaluation and management service(s) beyond the total time for the primary service … each additional 15 minutes …) for prolonged inpatient or observation E/M service codes 99223, 99233, and 99236
- G0317 (Prolonged nursing facility evaluation and management service(s) beyond the total time for the primary service … each additional 15 minutes by the physician or qualified healthcare professional …) for prolonged nursing facility E/M service codes 99306 and 99310
CMS and CPT® still at odds over when to add extra time. The Centers for Medicare & Medicaid Services (CMS) has made several changes to how you’ll code prolonged services in the last few years. Whether it’s the changes CMS implemented to prolonged service [...]
www.aapc.com
Coding for prolonged services
- There are two codes to use when coding for prolonged services for inpatient or observation visits, 99418 and G3016
- According to CPT®, you can also use 99418 in the nursing facility for prolonged care, but CMS requires G0317.
- CPT® does not have a prolonged care code for care in a patient’s home or in a residence such as assisted living, but there is a HCPCS code, G0318.
- And, CPT® and CMS again disagree on the threshold times required to report these 15-minute add-on codes. In a break from the past, CMS is using the times in the Medicare time file not the times in the CPT® book for G0316, G0317 and G0318.
- And, here’s the chart from CMS. Table 24 from the Final rule