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Prolonged Services
Note: View NGS’ Prolonged Services Timetable for CPT codes and time requirements.
- Please explain why time thresholds for some E/M services vary between AMA/CPT and CMS guidance.
Answer: The CMS RVU RUC assessed longer timeframe thresholds for the base E/M codes for same-day admission and discharge, for initial and subsequent services in the SNF and Home/Residence, and for Cognitive Assessment services. For Medicare billing, these longer threshold times must be completed before adding a prolonged service to the base code for these services.
- Please explain the status of former codes used for prolonged service reporting.
Answer: CPT Codes 99358–99359 have been declared invalid in 2023 by CMS. CPTs 99417–99418 are AMA codes that are invalid for use on Medicare claims.
- Please define code sets for which prolonged services do not apply and cannot be added.
Answer: Prolonged services are not applicable to ED services 99281-99285, critical care services 99291–99292 and discharge services 99238–99239.
- Please define parameters for CPTs 99415–99416 for prolonged service time spent by clinical office staff.
Answer: These codes may only be added to a claim on the same DOS as a base code representing a face-to-face encounter by a physician or NPP. The codes require completion of a full 30 minutes of additional face-to-face time by clinical office staff and cannot be used to represent time awaiting test results or time for diagnostic services elsewhere in the office suite. Of note, these codes do not apply in the facility setting, since clinical staff in the facility setting are not employed by the physician/group who are performing the base E/M service.
- Do prolonged service codes apply to services that are coded based on either time or MDM?
Answer:Prolonged service codes only apply to services that are coded based on time, and only when the service supports the highest level of coding within the appropriate code set. The concept of prolonged service does not apply to services coded based on the complexity of MDM.
- Do prolonged service codes apply to ED services (99281-99285)?
Answer: No, prolonged service codes do not apply to ED services, since ED services are not reported based on time spent with the patient.
- Do prolonged service codes apply to discharge services (99238-99239)?
Answer: No, prolonged service codes do not apply to discharge services, since 99239 allows for unlimited additional time spent performing the discharge service.
- Do prolonged service codes apply to critical care services (99291-99292)?
Answer: No, prolonged service codes do not apply to critical care services, since 99292 is used to represent one or more units of additional time spent beyond the base code 99291.
- Please explain the status of CPT Codes 99354-99357, previously used to represent prolonged service(s) in other than outpatient or office settings.
Answer: CPT Codes 99354-99357 have been deleted and are no longer in use.
- Please explain the status of CPT Codes 99358-99359, previously used to represent prolonged service(s) on a date different from the E/M service date.
Answer: CMS has designated an inactive status for these codes and they are no longer in use.
- Please define usage for CPT Codes 99415-99416 to represent prolonged clinical staff services.
Answer: These codes are used to describe the first hour (99415) and each additional 30 minutes (99416) of clinical staff time spent after an office or outpatient E/M service by a physician or NPP. These codes require direct patient contact by the clinical staff member and cannot be used to represent time spent awaiting test results or time spent elsewhere in the office or outpatient setting.
Reviewed 10/8/2024