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Ask a Rev Cycle Expert: Alternate Coding for CPT 99417?

Question:

Please advise how to price CPT® code 99417 for prolonged E/M services. CPT® code 99417 became effective 1/1/2021, but Medicare does not allow this service on any outpatient bill type. We use the information from the fee schedules to build our fees, so how would I set this up?

Answer:

Healthcare Common Procedure Coding System (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) (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) has been created to report prolonged services provided by the physician or qualified healthcare professional (QHP) due to a disagreement between the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) regarding when the prolonged services code should begin. HCPCS code G2212 has different reporting requirements for the initial time reporting.

According to the calendar year 2021 Medicare Physician Fee Schedule (MPFS) Final Rule, HCPCS code G2212 should not be reported until minute 89 is spent for Current Procedural Terminology (CPT®) code 99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter, or at minute 69 for CPT® code 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.

Disclaimer: This information was current at the time of its publishing and is designed to provide accurate information in regard to the subject matter covered. Vitalware does not accept any responsibility or liability with regard to any errors, omissions, misuses, or misinterpretation by the reader. It is not intended to take the place of either the written policies or regulations. We encourage you to review the specific regulations and other interpretive materials as necessary. All CPT® codes are trademarked by the American Medical Association (AMA) and all revenue codes are copyrighted by the American Hospital Association (AHA).