Breaking Down the 2023 E/M Prolonged Service Guidelines into Digestible Nuggets with Scenario Examples

by Mrs. Jay, Curriculum Director of Absolute Medical Coding Institute. 

Mastering Prolonged Services Coding: A Guide to 99415 and 99416

Healthcare providers often spend more time with patients than anticipated due to their complex medical needs. In these situations, it’s crucial to understand the billing and coding guidelines to ensure fair reimbursement for the additional time and effort. This blog post will delve into prolonged service codes 99415 and 99416, designed to address such situations. We’ll discuss the specific requirements for using these codes and tips to ensure accurate and compliant billing.

Understanding Prolonged Services Codes 99415 and 99416

What are Prolonged Service Codes 99415 and 99416?

Prolonged service coding 99415 and 99416 are used by supervised clinical staff to report additional time with a patient beyond the typical duration for a specific service. These codes are meant to be used with primary Evaluation and Management (E/M) services to represent the extended time spent on a patient’s care. For clarity, let’s define the following:

• Clinical staff: Medical assistants, licensed practical nurses, registered nurses, technicians, and others who are supervised by physicians or Qualified Healthcare Professionals (QHPs).
• Primary E/M service: Services carried out by the physician or QHP during the same session as the clinical staff.
• Typical duration/time: The time the clinical staff typically spends with a patient for a particular level of service.
• Prolonged clinical staff time: The time beyond the typical duration/time.

The Code Language for 99415 and 99416

99415: Prolonged clinical staff service during an evaluation and management service in the office or outpatient setting, involving direct patient contact with physician supervision; first hour (list separately in addition to the code for the outpatient Evaluation and Management service).

99416: Each additional 30 minutes (list separately in addition to the code for prolonged service).

When to Use Prolonged Service Codes 99415 and 99416

Prolonged service code are applicable when a supervised clinical staff member spends 30 minutes beyond the highest typical time for a specific level of service. In 2023, CPT introduced a typical time chart, detailing the documented typical time for each primary level of service code. Prolonged time begins (99415) when the time exceeds the typical duration by 30 minutes.

For example, if the primary level of service code is 99202, the typical time ranges from 29 to 58 minutes. Prolonged time begins once the total time reaches 59 minutes (30 minutes beyond the typical 29 minutes).cal time is 29 to 58 minutes. When the time reaches 59 minutes (30 minutes beyond the typical 29 minutes), prolonged time begins.

In the same example, 99416 is used when the time for 99202 reaches 104 minutes.

The typical time chart is not applicable if the documentation specifies prolonged time. Using the chart may lead to incorrect results and a potential loss of earned prolonged time. This issue arises because the typical time is assumed to have been considered when only documenting prolonged time.

For example, if the clinical team records 75 minutes of prolonged time for a level 4 established patient encounter, coding with the typical time chart would result in 99214 and 99415. However, direct coding would yield 99214, 99415, and 99416.

This discrepancy occurs due to the 30-minute gap between the typical clinical staff times of 40 and 70 minutes. This gap makes it impossible to pinpoint the exact typical time. While we cannot determine whether the nurse spent 40 or 50 minutes in typical time, we know the clinical staff spent 75 minutes of prolonged time. This justifies using codes 99415 and 99416.

Key Guidelines Pertinent to 99415 and 99416 (H2)

• Prolonged service codes 99415 and 99416 apply to face-to-face time with clinical staff supervised by doctors or QHPs.
• Providers should use codes 99415 and 99416 in addition to a primary E/M service code.
• Do not code prolonged service for durations under 30 minutes.
• Use code 99415 when prolonged time occurs between 30 minutes and 1 hour.
• When documenting total time for supervised clinical staff, refer to the typical time chart to determine prolonged time.
• Avoid using codes 99415 and 99416 with 99416 and 99417.
• You can use code 99416 when the final prolonged minutes reach at least 15 minutes.

Application to Practice

Scenario #1:

Dr. Sanchez, a primary care physician, has a follow-up appointment with Mr. Jacobs, a 65-year-old patient. Mr. Jacobs has a history of uncontrolled diabetes, hypertension, and recently diagnosed peripheral neuropathy. During the appointment, Dr. Sanchez conducted a medically appropriate exam with low medical decision-making (MDM).

However, due to Mr. Jacobs’s complex medical history, Dr. Sanchez asked his LPN to provide instructions for managing his condition at home. These instructions included soaking in Epsom salt, wearing compression socks, resting, applying ice, conducting daily feet checks, massaging, using anesthetics, and avoiding alcohol.The nurse spent a total of 55 minutes with the patient.

Code the encounter: 99213

Rationale: The doctor’s visit has a low MDM for the established patient; thus, the code is 99213, and no prolonged time for the nurse is coded; the nurse’s total time spent during the encounter (55 minutes) falls within the typical time range for a 99213 level of service.

Scenario #2: (H3)

Dr. Xia provided a medically appropriate history and exam with moderate medical decision-making (MDM) during John’s follow-up visit for diabetes. Nurse Johnson, an RN, spent a total of 130 minutes of total time with John, including addressing complex medical issues and developing and coordinating daily management plans with the patient.

Code for the encounter: 99214, 99415, 99416 x2

Rationale: Moderate MDM level of service is coded to 99214. If the nurse spent 130 minutes with the patient, according to the typical time chart (above) for the level of service, 99214, 99415, and 99416 are used for up to 115 minutes. If you subtract the total minutes (130) from 115 minutes, we are left with 15 minutes. 99416 is permitted if there are any remaining minutes of at least 15 minutes.

Proper Documentation for Prolonged Services 99415 and 99416

To accurately and compliantly bill for prolonged service codes, healthcare providers must maintain detailed documentation that supports the additional time spent on patient care. This documentation should include the following:

• The total duration of the visit, including the start and end times.
• A clear explanation of the medical necessity for the extended time, including the complexity of the patient’s condition or the need for additional counseling, coordination of care, or treatment planning.
• A description of the specific activities performed during the additional time.
• Confirmation that the additional time was spent under the direct supervision of the billing physician.

Conclusion

Prolonged service codes 99415 and 99416 enable practices to receive fair compensation for additional time spent by supervised clinical staff. By understanding the requirements for using these codes and maintaining accurate documentation, providers can confidently bill for these services and ensure appropriate reimbursement.

For more on Prolonged service read this article by AHIMA