Prolonged Service Codes & Changes through 2020 to 2024

Outpatient Prolonged Service

A New prolonged service code 99417 and G2212 for office visit was added in 2021. It was to be used with office visit CPT Codes only. We were using other prolonged service code (99354 and 99355) until the December 2023.

To reduce the documentation burden new guidelines were followed for office visit codes only and during that new code 99417 for non-Med payor and G2212 for Medicare Payor were introduced. Each of them needs each additional 15 minutes for its assignment.

EM 2024 guidelines effect on prolonged service:

In 2023, a conflict arose between the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) regarding the time requirements for prolonged service codes. The AMA used CPT code 99417 for prolonged service, while CMS used G2212.

Both codes required the completion of a full 15 minutes for reporting. The AMA calculated this 15-minute period from the lower time limit of 99205, which has a range of 60 to 74 minutes. In contrast, CMS calculated the 15-minute period from the upper limit of the E/M code that is from 74 minutes.

This difference led to confusion in coding. For instance, if a provider spent 75 minutes with a patient in an office setting, according to AMA guidelines, the encounter could be coded as 99205 and 99417. However, according to CMS guidelines, G2212 should be used if 15 minutes were completed beyond 74 minutes, which means here it would be only coded with 99205 and CMS would only allow to code 99205. To code 99205 + G2212, the total time spent should be 89 minutes, including 15 minutes beyond the initial 74 minutes.

To address this confusion, the AMA removed the time range requirement for prolonged service codes in 2024. This change simplifies the coding process and reduces confusion for medical coders, ensuring that providers can accurately report the time spent on patient care.

Now, If a provider spends 74 minutes, it would be coded with 99205 and 99417 according to AMA, and same would be followed by SMS 99205 and G2212.

Prolonged Service Code 99418 for Inpatient Care

The American Medical Association (AMA) introduced code 99418 in 2023 for reporting prolonged inpatient or observation evaluation and management (E/M) services beyond the typical service time of the base E/M code.

Previous Codes and Replacement: Previously, providers used codes 99356 and 99357 for prolonged services involving direct patient contact in inpatient settings. These codes were replaced in 2023 by 99418 for all inpatient settings.

Medicare Substitute Codes: Medicare patients have specific substitute codes for prolonged inpatient care: G0316, G0317, and G0318. These G-codes are used to report prolonged inpatient E/M services beyond the typical service time of the base E/M code.