CPT
Code 99496 covers communication with the patient or caregiver within two business days of discharge. This can be done by phone, e-mail, or in person. It involves
medical decision making of high complexity and a face-to-face visit within seven days of discharge
Codes 99358 and 99359 are used when a prolonged service is provided that is neither face-to-face time in the outpatient, inpatient, or observation setting, nor additional unit/floor time in the hospital or nursing facility setting & may also be used for prolonged services on a date other than the date of a face-to face encounter.
Prolonged Office/Outpatient E/M Visits
Effective January 1, 2021, CMS is finalizing HCPCS code G2212 for prolonged office/outpatient E/M
visits. HCPCS code G2212 is to be used for billing the MPFS instead of CPT code 99358, 99359 or 99417,
with the following descriptor: “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) “(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).”
Please see the attached document titled: Prolonged Office Outpatient Evaluation and Management Reporting
Times. The tables displayed within the document delineate required times for reporting prolonged
office/outpatient E/M visits. When the time of the reporting practitioner is used to select the office/outpatient
E/M visit level, HCPCS code G2212 could be reported when the maximum time for the level 5
office/outpatient E/M visit is exceeded by at least 15 minutes on the date of the service.
Office/Outpatient E/M Visit Complexity Add-On
Starting in 2021, there will be a new, Medicare-specific add-on code to report office/outpatient E/M visit
complexity. It is HCPCS code G2211, “Visit complexity inherent to evaluation and management associated
with medical care services that serve as the continuing focal point for all needed health care services and/or
with medical care services that are part of ongoing care related to a patient’s single, serious, or complex
condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit,
new or established).” This code reflects the time, intensity, and practice expense when practitioners furnish
services that enable them to build longitudinal relationships with all patients (that is, not only those patients
who have a chronic condition or single-high risk disease) and to address the majority of patients’ health care
needs with consistency and continuity over longer periods of time. This includes furnishing services to
patients on an ongoing basis that result in a comprehensive, longitudinal, and continuous relationship with
the patient and involves delivery of team-based care that is accessible, coordinated with other practitioners
and providers, and integrated with the broader health care landscape. For example, in the context of primary
care, HCPCS add-on code G2211 could recognize the resources inherent in holistic, patient-centered care
that integrates the treatment of illness or injury, management of acute and chronic health conditions, and
coordination of specialty care in a collaborative relationship with the clinical care team. In the context of
specialty care, HCPCS add-on code G2211 could recognize the resources inherent in engaging the patient in
a continuous and active collaborative plan of care related to an identified health condition the management
of which requires the direction of a clinician with specialized clinical knowledge, skill and experience. Such
collaborative care includes patient education, expectations and responsibilities, shared decision-making
around therapeutic goals, and shared commitments to achieve those goals. In both examples, HCPCS add-on
code G2211 reflects the time, intensity, and PE associated with providing services that result in care that is
personalized to the patient. We are not restricting billing based on specialty, but do assume that certain
specialties furnish these types of visits more than others
FAQ on Transitional Care Management
Frequently asked questions about transitional care management, including what it is, how and when to bill for it, and what services are covered.
www.aafp.org
