Prolonged service codes provide a valuable opportunity for medical practices to earn additional revenue when a clinician spends extra time providing care to a patient. These codes are specifically designed to be used in conjunction with office-based Evaluation and Management (E/M) visits, allowing practices to report extended service time beyond the typical office visit.
Here’s what medical coders need to know about prolonged service codes:
Key Facts About Prolonged Service Codes and Office E/M Visits:
- Prolonged Service CPT Codes 99417 and 99415-99416: These codes can be used with office visit codes 99205 or 99215 when the visit is documented based on time. However, facilities cannot report codes 99415-99417.
- Time Exclusions: Time spent on other separately billed services, such as diagnostic tests, cannot be included when calculating prolonged service time.
- Same-Day Requirement: Prolonged service codes (CPT 99417 and 99415-99416) must be reported for services performed on the same calendar day as the face-to-face encounter.
- Reporting Prolonged Time on Different Dates: If the additional time occurs on a separate date from the face-to-face visit, report CPT codes 99358-99359.
- Multiple Prolonged Service Codes: You cannot report multiple prolonged service codes for the same patient on the same day. For example, CPT 99417 cannot be reported along with 99415-99416 on the same date.
When to Use Prolonged Service Codes:
- Level 5 Office/Home Visits: If the total time for an office visit exceeds the allotted time for a level 5 office visit by at least 15 minutes, you can report the CPT code 99417. This code was introduced by the AMA to accommodate the need for a shorter time threshold for prolonged services.
- CPT 99417 can be reported alongside 99205, 99215, 99245, 99345, 99350, or 99483.
- Requirements: To report one unit of service, the encounter must be time-based, and the clinician’s documentation must show at least 15 minutes of prolonged service time on the same day as the primary E/M visit.
Prolonged Service in Facility Settings:
In a facility setting, prolonged services are reported with CPT code 99418. This code applies when the total time for the inpatient or observation service exceeds the typical duration for the selected level of service by at least 15 minutes.
- Facility Reporting: Report CPT code 99418 with inpatient and observation E/M codes such as 99223, 99233, 99236, 99255, 99306, and 99310.
By understanding and applying these codes correctly, medical coders can ensure accurate reporting, optimize revenue for extended patient encounters, and support clinicians in their detailed documentation.