2021 E/M Prolonged Service Billing Changes for Medicare
National Government Services has received several inquiries regarding changes to office or other outpatient prolonged service coding effective 1/1/2021.
When the AMA released the changes to 2021 office or other outpatient services, they established CPT code 99417 for prolonged services for 15 minute increments beyond the maximum time represented by CPT codes 99205 and 99215.
The CMS was part of the AMA workgroup that determined prolonged services should be billable in shorter increments and agreed with the concept that a 15 minute prolonged service code was appropriate. However, the AMA issued the prolonged service code with the instruction that it may be billed one (1) minute beyond the maximum time of 99205 and 99215. CMS policy indicates that to bill for a service you have to meet the definition of the service code. Therefore, CMS has created a different code for prolonged services with office or other outpatient services to be reported for Medicare; G2212.
The code description for G2212 is, “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).”
To clarify, to report prolonged services for office or other outpatient services for Medicare the appropriate billing is G2212. CPT 99417 is NOT allowed for Medicare billing. If 99417 is billed it will be rejected on Medicare submission as an inappropriate code.
The code description and other information above was taken directly from Change Request 12071 which announced 2021 Medicare Physician Fee Schedule Final Rule changes to the Medicare program. Also included in CR12071 are the tables shown below that provide an overview of billing the prolonged service code, G2212, for Medicare purposes. The complete version of this information is found in MLN Matters® MM12071: Summary of Policies in the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List
Posted 12/11/2020