by Mrs. Jay, Curriculum Director of Absolute Medical Coding Institute.
Evaluation and Management (E/M) prolonged service are essential tools for healthcare providers and clinical teams to accurately capture and bill for the additional time spent on patient care beyond the time for the highest level of service or typical E/M service. This blog series will explore the specifics of prolonged service codes 99417 & 99418, 99358 & 99359, and 99415 & 99416, their appropriate usage, tips for successful documentation, and scenario examples for each code in 2023 according to the CPT changes.
Understanding Prolonged Service Codes 99417 and 99418
99417 and 99418 are prolonged service codes used to account for extended time spent on a patient’s care that goes beyond the usual service time associated with specific E/M codes carried out In the office or other outpatient E/M service and inpatient. Let’s begin with reviewing the code language.
99417: Prolonged outpatient evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time (List separately in addition to the code of the outpatient Evaluation and Management service). 99417 is specifically used with 99205, 99215, 99245, 99345, 99350, and 99483.
99418: Prolonged inpatient or observation evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time (List separately in addition to the code of the inpatient and observation Evaluation and Management service). 99418 is specifically used with: 99223, 99233, 99236, 99255, 99306, and 99310.
When to Use Prolonged Service Codes 99417 and 99418
Use prolonged service codes 99417 and 99418 when a Dr. or Qualified Healthcare Professional (QHP) spends significantly beyond the usual service time for a specific E/M code. The additional time must be: 15 minutes.
- 99417 prolonged service must occur in the office/other outpatient settings (99205, 99215, 99245, 99345, 99350, 99483)
- 99418 prolonged service must occur in the inpatient setting ( 99223, 99233, 99236, 99255, 99306, 99310)
- 99417 and 99418 must be used on the same day as the primary service (E/M visit)
- Prolonged time begins 15 minutes after the highest time allowed for the pertinent primary service
- The primary service must use time (not MDM) to document the level of service
- The prolonged service can be face-to-face or non-face-to-face (see the approved non-face-to-face activities)
- 99417 and 99418 are add-on codes and must be coded in addition to the primary service code
- 99417 and 99418 used for each 15 minutes of prolonged time
- Do not use 99417 and 99418 for any unit of time less than 15 minutes
- 99417 and 99418 can only be used by physicians/QHPs
Proper Documentation for Prolonged Services
Thorough documentation is crucial when billing for prolonged services to ensure accurate reimbursement and avoid potential audits. Key elements to include in your documentation are:
- The start and end times of the prolonged service
- A detailed explanation of the additional services provided during the prolonged period
- A clear description of the medical necessity for the prolonged service
- The primary E/M service code with which the prolonged services code is billed
- Scenario Examples
Application to practice:
a. Scenario for 99417:
A primary care physician, Dr. Smith, sees an established patient for a 30-minute office visit (99214). During the visit, Dr. Smith realizes the patient’s condition is more complex than anticipated and spends an additional 60 minutes reviewing the patient’s records, consulting with a specialist, and developing a comprehensive treatment plan. Code for Dr. Smith:
In this case, Dr. Smith can bill 90 minutes of time on the day of the encounter for face-to-face and non-face-to-face time spent on the patient’s care. In other words, the time the Dr. spent with the patient and on the patient’s behalf should be documented on the same day should be documented. If we use the E/M time chart for established patients:
You would code for the highest level of service, which is 54 minutes.
Then you would subtract 54 minutes from the total 90 minutes (90-54= 36). With 36 minutes being prolonged time.
Go to code 99417, and see that the total time is determined by 15-minute increments, then divide 36 minutes by 15 (36/15) = 2.4, we can only code 2 units of 99417, because you may not code any unit less than 15
Final answer: 99215, 99417×2
b. Scenario for 99418:
A patient is admitted to the hospital for suspected AMI, and a cardiology consultant visits the patient at the request of the attending. The consultant spends 2.5 hours (150 minutes) working up the patient and ruling out AMI, then documents his findings to the attending. Code for the Cardiologist:
In this case, the Cardiologist’s visit can be coded as a consultant because the 3 R’s took place, Request from an appropriate source, service was Rendered, and a Report was written back to the requester. If we use the CPT E/M chart, we can code for the highest level for an inpatient consultation which is: 99255
The time for 99255 is 80 minutes. Since the total time of the encounter is 150 minutes, subtract 80 minutes from 150 minutes (150 – 80 = 70) With 60 minutes of prolonged time. Next, we turn our attention to the prolonged time code 99418 to select our units. Dividing 80 by 15 units for a total of 4.6666 units. Any amount under 15 units can not be coded thus only 4 units of 99418 can be coded.
Final answer: 99255, 99418×4
Tips for successfully billing prolonged services of 99417 & 99418:
To increase the chances of successful reimbursement for prolonged services, consider the following tips:
- Differentiate the prolonged service time from the time spent on the primary E/M service.
- Ensure the total time spent on the prolonged service is accurately documented, including start and end times.
- Use the 99417/99418 codes in 15-minute increments; both can be reported multiple times as long as each increment is justified.
- Confirm that the primary E/M service code meets the required criteria before appending prolonged service codes.
- Document the medical necessity for the prolonged service and the additional tasks performed during that time.
Prolonged service codes 99417 and 99418 are essential for healthcare providers to accurately document and bill for the additional time spent on patient care beyond the standard E/M services. By understanding the appropriate usage of these codes and their guidelines, maintaining thorough documentation, and following best practices for billing/coding, healthcare providers can ensure they receive fair compensation for their extended efforts in patient care. With the help of the scenario examples provided in this blog post, you should now have a better understanding of how to apply these codes in various situations, enabling you to confidently navigate the world of medical coding in 2023.
1. AMA CPT 2023, page xxv
2. AMA CPT 2023 page 29
3. AMA CPT 2023, page xxvi
4. AMA CPT 2023, page 29
5. AMA 2023 E/M descriptors – https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf