Breaking Down 99417 and 99418 E/M Prolonged Service Guidelines into Digestible Nuggets with Scenario Examples. (Pt. 1 of 3 Series)

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

Understanding Prolonged Service Codes 99417 and 99418 in Medical Coding

Understanding Prolonged Service Codes 99417 and 99418 in Medical Coding
Prolonged service codes 99417 and 99418 are essential tools for healthcare providers and clinical teams to accurately capture and bill for additional time spent on patient care beyond the standard Evaluation and Management (E/M) service duration. This blog series will explore the specifics of these codes, including their appropriate usage, tips for successful documentation, and practical scenarios for each code in 2023, in line with the latest CPT changes.

Prolonged Service Codes Overview

Healthcare providers use codes 99417 and 99418 to account for extended time spent on patient care that exceeds the usual service time for specific E/M codes. Let’s review the code language:

99417: This code represents prolonged outpatient evaluation and management service time, with or without direct patient contact, that goes beyond the required time of the primary service. Providers should list this code separately in addition to the primary outpatient E/M code when selecting the primary service level using total time. Specifically, 99417 is associated with the following codes: 99205, 99215, 99245, 99345, 99350, and 99483.

99418: In contrast, this code pertains to prolonged inpatient or observation evaluation and management service time, again with or without direct patient contact, beyond the required time of the primary service. Providers should list this code separately in addition to the primary inpatient and observation E/M code. 99418 specifically associates with codes: 99223, 99233, 99236, 99255, 99306, and 99310.

When to Use Prolonged Service Codes

Healthcare providers should apply prolonged service codes 99417 and 99418 when they spend significantly more time than the usual service time for a specific E/M code. The additional time must amount to at least 15 minutes.

Key Guidelines:

  • 99417 applies to office or other outpatient settings (e.g., 99205, 99215, 99245, 99345, 99350, 99483).
  • 99418 applies to inpatient settings (e.g., 99223, 99233, 99236, 99255, 99306, 99310).
  • Both codes must appear on the same day as the primary service (E/M visit).
  • Prolonged time begins after 15 minutes beyond the maximum allowed time for the pertinent primary service.
  • The primary service must utilize time (not medical decision-making) to document the service level.
  • Providers can report prolonged service for face-to-face or non-face-to-face activities (see approved non-face-to-face activities).
  • 99417 and 99418 are add-on codes, meaning they must accompany the primary service code.
  • Each additional 15 minutes of prolonged time can receive separate coding.
  • Providers should not use 99417 and 99418 for any time units less than 15 minutes.
  • Only physicians or qualified healthcare professionals (QHPs) can use these codes.

Proper Documentation for Prolonged Services

Thorough documentation is crucial for billing prolonged services to ensure accurate reimbursement and avoid potential audits. Key elements to include 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

Scenario for 99417

Dr. Smith, a primary care physician, 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 records, consulting a specialist, and developing a treatment plan.

Guidelines for Prolonged Service Codes 99417 & 99418

Using the E/M time chart, 36 minutes translates to 2.4 units of 99417, but only 2 units can be coded since any unit less than 15 minutes cannot be billed. Total Time: 90 minutes (30 minutes for the visit + 60 minutes for additional time).The highest level of service coded is for 54 minutes. Therefore, subtracting this from the total time gives us 36 minutes of prolonged time (90 – 54 = 36).

Final Code: 99215, 99417 x 2

Scenario for 99418

A patient is admitted to the hospital for suspected Acute Myocardial Infarction (AMI). A cardiology consultant visits the patient, spending 2.5 hours (150 minutes) working up the patient and ruling out AMI.

A patient is admitted to the hospital for suspected Acute Myocardial Infarction (AMI). A cardiology consultant visits the patient, spending 2.5 hours (150 minutes) working up the patient and ruling out AMI.Dividing 70 minutes by 15 results in 4.67, allowing for 4 units of 99418 to be billed.Consultation Code: 99255 is the highest level for inpatient consultations, coded for 80 minutes.Subtracting this from the total time gives us 70 minutes of prolonged time (150 – 80 = 70)

Final answer:  99255, 99418×4

Tips for Successfully Billing Prolonged Services 99417 & 99418

To improve your chances of successful reimbursement for prolonged services, consider the following tips:

  • Clearly differentiate the prolonged service time from the primary E/M service time.
  • Accurately document the total time spent on prolonged services, including start and end times.
  • Report 99417/99418 codes in 15-minute increments, ensuring justification for each.
  • Confirm that the primary E/M service code meets required criteria before appending prolonged service codes.
  • Document the medical necessity for the prolonged service and the additional tasks performed during that time.

Conclusion

Prolonged service codes 99417 and 99418 are vital for healthcare providers to document and bill for extra time spent on patient care beyond standard E/M services. By understanding their appropriate usage, maintaining accurate documentation, and following billing best practices, providers can ensure fair compensation for their efforts. The provided scenario examples enhance your confidence in applying these codes effectively in 2023.

References:

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