Although in general, I believe most clinicians can code for most of the work they do (not a universally held opinion, I know) this is a case where the claims must go to a coder for review. IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK ABOVE ON THE LINK LABELED "I Do Not Accept" AND EXIT FROM THIS COMPUTER SCREEN. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. *IMPORTANT NOTE: The new add-on prolonged services codes G2212 and 99417 will NOT BE EFFECTIVE UNTIL 2021; do not use these new codes for services prior to January 1, 2021. G0317 (Prolonged nursing facility 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 99306, 99310 for nursing facility evaluation and management services). Barbara Aubryis a senior regulatory analyst with 3M Health Information Systems. You can only use codes 99417 This bundle includes the E/M quick reference card, a great tool for quickly identifying the different criteria and time ranges associated with the new E&M coding changes. %PDF-1.6 % HCPCS code G2211 is an add-on code and can be billed separately in addition to new or established patient office/outpatient E/M codes. The AMA is a third-party beneficiary to this license. Whether its the changes CMS implemented to prolonged service coding with the 2023 final rule, or the different ways Medicare and payers who follow CPT guidelines code for prolonged services, things are getting tricky when trying to report these services. Payment Rates for Medicare Physician Services - Evaluation and Management CPT Code; Descriptor; NON-FACILITY (OFFICE) FACILITY . Do not report G0318 on the same date of service as other prolonged services for evaluation and management. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. There is no replacement of these services for Medicare patients. Discharge Day Management (99238-9), 1 day before visit + date of visit +3 days after, 3 days before visit + date of visit + 7 days after, Cognitive Assessment and Care Planning (99483). Coding for Evaluation and Management Services: Answers to Common Questions Evaluation and management (E/M) services are at the core of most family medicine practices and represent a category. For Medicare patients, there is a HCPCS code. Get timely coding industry updates, webinar notices, product discounts and special offers. However, for a Medicare patient, you would not be able to bill 99223 with G0316 in this situation as even though 99223 may have been exceeded by 15 minutes, the codes descriptor tells you not to report G0316 for any time unit less than 15 minutes. In this case, the unit of the prolonged service time, 5 minutes, is less than 15 minutes, so you will only bill Medicare for the 99223 service. Helps here: This article will discuss all the new codes, and coding conventions, that are part of prolonged services coding in 2023. 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 ). The total time must be documented. There are different CPT and HCPCS codes that describe the same prolonged care services. Otherwise, the actual billing codes for E/M services remain the same. 3M takes your privacy seriously. MEDICAL REVIEW WHEN PRACTITIONERS USE TIME TO SELECT VISIT LEVEL Our reviewers will use the medical record documentation to objectively determine the medical necessity of the visit and accuracy of the documentation of the time spent (whether documented via a start/stop time or documentation of total time) if time is relied upon to support the E/M visit.. Even though CMS instructs providers to use G codes, there will be no additional payment for G2211 until January 1, 2024 or later; it is currently considered a bundled service. Hopefully, everyone is using the new E/M codes without issue. Practitioners should not report prolonged office/outpatient E/M visit time using CPT codes 99354 and 99355 (Prolonged service with direct patient contact), 99358 and 99359 (Prolonged service without direct patient contact), 99415 and 99416 (Prolonged clinical staff services), or 99417 (Prolonged office/outpatient E/M services with or without direct patient contact), HCPCS code 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 (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services). It is always important to properly document, but when a medical necessity audit is looming, be sure to include information that supports the decision making process. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. Some of the Provider information contained on the Noridian Medicare web site is copyrighted by the American Medical Association, the American Dental Association, and/or the American Hospital Association. CPT allows you to add the 15 minutes to the lower time threshold in the range, and CMS requires you to add the 15 minutes to the higher time threshold in the range. For hospital, nursing facility and home and residence services, CMS uses time on other dates of service. Privacy Policy, Compliance issues in ICD-10 coding for risk based contracts and HCCs, CPT Coding for Bronchoscopy Procedures | Webinar, CMS Split/Shared Services Rules | Reference Sheet, screening and counseling for behavioral conditions. CMS newly created HCPCS code G2212 is to be used for billing Medicare for prolonged Evaluation and Management (E/M) services which exceed the maximum time for a level five (99205, 99215) office/outpatient E/M visit by at least 15 minutes on the date of service. 99418 may be used on the highest-level initial and subsequent inpatient and observation codes, inpatient consult, and initial and subsequent nursing facility services. The entire 15 minutes must be done, in order to add on this new, prolonged services code. 371 0 obj <>stream Note: Coding regulations and edits can change often. endstream endobj startxref Please choose at least one subscription option. This is in the CPT and HCPCS definition of prolonged services. Use time one day before visit, date of visit and three days after visit, IP/Obs. It also included an extensive discussion with the patient and his sister about treatment options and recovery time, if he decides on surgery.. 99245 (Office or other outpatient consultation for a new or established patient ) when the time meets or exceeds 55 minutes The2023 time file is here. HCPCS code G2212 is as follows, "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 In their place, youll now use +99417, as CPT has increased its scope. Practitioners may report this code for qualifying visits furnished on or after January 1, 2021, although we assigned a PFS payment status indicator of B (Bundled) until 2024. Please click here to see all U.S. Government Rights Provisions. It included reviewing test results, documenting in the record and arranging for follow up at pain management. You cant report the new add on code on the same day as psychotherapy, non-face-to-face prolonged care codes 99358, 99359 or staff prolonged care codes. At any time, and for any lawful Government purpose, the government may monitor, record, and audit your system usage and/or intercept, search and seize any communication or data transiting or stored on this system. Biomechanical device placement and anterior instrumentation, Celebrating health information professionals, Top 6 reasons to attend the 2023 3M Client Experience Summit, Three questions with Garri Garrison: From pen and paper to hands free, COVID-19 compliance concerns Part 2 on PPE. For U.S. Government and other information systems, information accessed through the computer system is confidential and for authorized users only. BY CLICKING ABOVE ON THE LINK LABELED "I Accept", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THESE AGREEMENTS. In addition to the highest-level initial and subsequent nursing facility care E/M codes 99306 and 99310, youll use +99418 with the following revised codes: You may also contact AHA at [email protected]. Instead, CMS released HCPCS code G2212 to be used when billing 15 minutes of prolonged services for Medicare, including Medicare Advantage members. According to CMS: Trying to become comfortable with new codes is always a challenge and these added requirements are a bit confusing. CPT, In the 2021 final rule, CMS argued that you should use, If the patient has private insurance, you would bill 99223 and +99418 as +99418 may be used as soon as the total time [75 minutes] has been exceeded by 15 minutes, according to. y{O? %vYt{D&P*iI 00v3f|ti!lL3>"A@^N]LV``>rg "MUc`ZQ` a The CPT Editorial Panel's guidance was that prolonged services could be billed after a visit exceeds the minimum level 5 threshold by 15 minutes. The agency finalized new values for CPT codes 99202 through 99215 and assigned RVUs to the new office/outpatient E/M prolonged visit code G2212, as well as the new code G2211. You must log in or register to reply here. Learn more about solutions from 3M Health Information Systems. MPFS Conversion Factor a Tough Pill for 2023, Unless Congress acts, CF will be significantly cut. Register for our on-demand E/M education series. Information provided by our coding experts is copyrighted by the American Academy of Ophthalmology and intended for individual practice use only. For 2023, CPT also deletes prolonged service codes +99354 and +99355. (Do not report G0317 for any time unit less than 15 minutes)). Fortunately, the guidelines for using the code remain the same. CPT also deletes prolonged service codes +99356 and +99357 for 2023 and introduces another code: +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 ), which had been previously give the placeholder code of 993X0. In other words, 1-14 additional minutes of E/M service does not warrant a unit of G2212. (Do not report G2212 for any time unit less than 15 minutes) (Underlining is my addition.). CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Academy coding advice is based on current information. I think the question was prompted by the fact that for certain services provided by practitioners in a facility the add-on prolonged care codes includes time the days before or in the days after the face-to-face encounter. (Do not report G2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416). 3M and its authorized third parties will use the information you provided in accordance with our privacy policy to send you communications which may include promotions, product information and service offers. 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: First, consult the Clip & Save guide elsewhere in this article, then determine how you would code for inpatient care lasting 95 minutes for a patient who has just been admitted to the hospital. Not only are there different codes depending on payer, the time thresholds are different. Reproduced with permission. Whether its the changes CMS implemented to prolonged service coding with the 2023 final rule, or the different ways Medicare and payers who follow CPT guidelines code for prolonged services, things are getting tricky when trying to report these services. This bundle includes the E/M quick reference card, a great tool for quickly identifying the different criteria and time ranges associated with the new E&M coding changes. Do not report G0317 on the same date of service as other prolonged services for evaluation and management. Youll now be allowed to use it to report prolonged services with: CPT also deletes prolonged service codes +99356 and +99357 for 2023 and introduces another code: +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 ), which had been previously give the placeholder code of 993X0. 99231 -99233 Evaluation and Management Services 99 238 -99499 Evaluation and Management Services However, for Medicare beneficiaries or payers that publisha policystating they follow Medicare's guidelines for prolonged services reporting, the code to report would be G2212. See the CMS Table 24 below. No charge. These are important qualifiers, as medical necessity audits are likely to follow. Unauthorized or illegal use of the computer system is prohibited and subject to criminal and civil penalties. The disagreement stems from whether to start counting the 15 minutes of prolonged care at the minimum time threshold for the code or the maximum time threshold. Providers use Healthcare Common Procedure Coding System (HCPCS) Code G2212 to bill extended time for E/M services. However, Medicare does not cover 99417 and, instead, created HCPCS code G2212 to report this service. CPT still has non-face-to-face prolonged care in the CPT book, codes 99358, +99359 which can be used on days that do not include a face-to-face visit. Instead, in a break from prior policy, CMS is using the time in the CMS time file. Instead, use G2212, G0316, G0317, and G0318 . Recorded April Read More Download Reference Sheet She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. The CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. CMS is allowing time on days prior to and after the date of the encounter to be used for prolonged services in relation to home/residence visits. Providers must spend an entire 15 minutes providing E/M services for each unit of G2212 billed. (Do not report G0318 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99417). The information below is what was sent to us from our Medicaid program. CMS and CPT still at odds over when to add extra time. Last Updated Wed, 22 Mar 2023 12:22:35 +0000. Our expert staff have decadesof combined experience, covering all aspects of coding and reimbursement. CMS does not recognize consult codes. CMS does not recognize consult codes. 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). 99345/99350 (Home or residence visit for the evaluation and management of a new/established patient ) when the times meet or exceed 75 or 60 minutes, respectively For more about Betsy visit www.betsynicoletti.com. I spent 90 minutes caring for the patient today. (Do not report 99418 for any time unit less than 15 minutes). And wish I had started looking there in the first place! Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare and Medicaid Services (CMS). Lets see what CPT and CMS say. Yes. Prolonged Evaluation & Management codes underwent big changes in 2021, including the creation of a new prolonged code (99417), reportable only with codes 99205 or 99215. CPT Code Description for 99417 This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. Enjoy a guided tour of FindACode's many features and tools. It doesnt follow CPT typical times, or CPT prolonged services rules. Medical Necessity Don't use CPT codes to report these services. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. If you choose not to accept the agreement, you will return to the Noridian Medicare home page. Prolonged care services can no longer be used on psychotherapy codes. Since E/M services are such a large volume of the claims processed, CMS may choose to hire outside auditors. Both codes describe a prolonged office or other evaluation and management service that requires at least 15 minutes or more of time either with OR without direct patient contact on the date of the primary E/M service (either CPT codes 99205 or 99215) . Expect audits of all E/M claims that use time as the determining factor in choosing a code. As expected, CMS is not recognizing the new CPTcode 99418. 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 Cancel anytime. CPT is a registered trademark of the American Medical Association. G0318 (Prolonged home or residence evaluation and management service(s) beyond the total time for the primary service each additional 15 minutes ) for prolonged home or residence E/M service codes 99345 and 99350 MACs may be instructed to focus on specific codes or diagnoses, or even specific extra time units reported. Split/shared services Read More All content on CodingIntel is copyright protected. CPT codes 99417 and 99418 are not accepted for processing for Commercial or Medicare Advantage plans. Use CPT code times on the date of service only, Use time three days before visit, date of visit and 7 days after visit. E/M visit in each category by at least 15 minutes on the date of service. CPT instructs you to use +99417 when service times for 99205 (Office or other outpatient visit for the evaluation and management of a new patient 60-74 minutes of total time is spent on the date of the encounter) or 99215 (Office or other outpatient visit for the evaluation and management of an established patient 40-54 minutes of total time is spent on the date of the encounter) go 15 minutes beyond the minimum for the 99205/99215 time ranges 75 minutes for a new patient visit and 55 for an established patient and additional units for every 15 minutes beyond those times. Please choose at least one topic center option. The work of the prolonged care may include both face-to-face and non-face-to-face time. The use of the information system establishes user's consent to any and all monitoring and recording of their activities. hb```f``;Ab,fk27Xs&Y \-2=nqgm * Time must be used to select visit level. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. And the same goes for a new patient? o New CPT code 99417 can be reported for each 15 minutes of prol onged care performed on the same day beyond the maximum time listed for E/M codes 99205 and 99215. Retrieved from https://www.findacode.com/articles/how-to-properly-report-prolonged-services-using-99417-or-g2212-36784.html. CPT codes 99417 and 99418 will be denied with one of the following: Denial explanation code: 53B This procedure code is not accepted for processing by Moda Health for When they were applicable to all levels of service, the threshold time was different for each code. If the patient's condition does not warrant a 99205 or 99215 level of care, then it does not matter how long the provider spent caring for the patient, G2212 technically should not be reported. Can an add-on code to be submitted without its primary code? As we learn more, we will continue to provide updates on this important topic. 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 CPTcodes 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. Do not report G0316 for any time unit less than 15 minutes. G2212 Prolong outpt/office vis 0.96 $32.24 0.97 $33.85 -4.7% 0.93 $31.23 0.93 $32.45 NEW CODE . CPT/HCPCS Codes Descriptor . Providers continue to use CPT codes 99202 through 99205 to bill for E/M services for new patients, and CPT codes 99211 through 99215 for established patients. The ADA is a third-party beneficiary to this Agreement. While Medicare has agreed to accept the AMA's CPT E/M coding changes, they have formulated an opinion contrary to how CPT calculates time specific to reporting this prolonged service code, and has created a separate HCPCS code (G2212) for reporting prolonged services specific to 99205 and 99215. CMSs manual does not currently require start and stop times. Just a few reminders. %%EOF Thirty-five minutes with a patient would be reported as two units of G2212, etc. CPT instructs you to use +99417 when service times for 99205 (Office or other outpatient visit for the evaluation and management of a new patient 60-74 minutes of total time is spent on the date of the encounter) or 99215 (Office or other outpatient visit for the evaluation and management of an established patient 40-54 minutes of total time is spent on the date of the encounter) go 15 minutes beyond the minimum for the 99205/99215 time ranges 75 minutes for a new patient visit and 55 for an established patient and additional units for every 15 minutes beyond those times. Therefore, you have no reasonable expectation of privacy. To align TRICARE policy with Medicare policy, providers should use HCPCS code G2212 (each additional 15 minutes, but not less than 15 minutes), when billing for prolonged services in addition to Current Procedural Terminology (CPT) codes 99205, 99215 or 99483. 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 ).
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