Wound/ulcer management physicians and other qualified healthcare professionals (QHPs) realize the importance of conducting thorough initial wound/ulcer assessments and ordering diagnostic/imaging tests before developing a plan of care for patients with high-risk, complicated wounds/ulcers. In addition, further in-depth evaluation and management (E/M) services may be required if the high-risk, complicated wounds/ulcers do not respond to the treatment plan. Because these E/M services often require more time than is allotted in level 5 new or established E/M services, new prolonged services codes 99417 and G2212 were created. Following are the most frequently asked questions and answers about these two relatively new codes.
Q: Is it true that there are two different new codes for physicians/QHPs to report prolonged E/M services in the office or provider-based department (PBD)?
A: Yes, in 2021 the prolonged services E/M codes were significantly changed, and two new codes were created. Both the new CPT (Common Procedural Terminology) code 99417 and the new HCPCS (Healthcare Common Procedure Coding System) code G2212 describe a prolonged office or PBD E/M service that requires at least 15 minutes or more of time, either with or without direct patient contact, on the same day as when level 5 new (99205) or established (99215) E/M service is performed (Table).
The American Medical Association created 99417, which should only be reported in addition to level 5 new (99205) or established (99215) E/M codes that are reported based on time. The American Medical Association code (99417) starts counting the 15 minutes of prolonged services at the minimum time threshold in the code descriptions of 99205 and 99215.
The CMS disagreed about how the prolonged service time should be calculated. The CMS believes the prolonged services should start counting the 15 minutes of prolonged services after the maximum time threshold in the code descriptions of 99205 and 99215 has been exceeded by 15 minutes. Therefore, CMS established its own new code (G2212) and definition for physicians/QHPs to report prolonged E/M services in the office or PBD.
Because two different prolonged E/M service codes now exist, physicians/QHPs should report 99417 to private payers who do not follow Medicare guidelines and report G2212 to Medicare and any other payers who declare they are following Medicare's guidelines for reporting prolonged E/M services.
Both codes can only be used when the physician/QHP chooses to report medically necessary E/M services based on "time" spent on the day of the E/M encounter.
Q: How does calculating prolonged services time differ for 99417 and G2212?
A: Physicians/QHPs should first verify how their Medicare Administrative Contractor and pertinent private payers require time to be documented. Some payers may only require total time to be documented, whereas others may require documentation of start and stop times throughout the day of the encounter. Physicians/QHPs should also verify if the payer has any coverage requirements pertaining to 99417 and G2212. Then, physicians/QHPs should refresh their understanding of the minutes of time that are built into 99205 (60-74 minutes) and into 99215 (40-54 minutes). Finally, physicians/QHPs should document if the patient is "new" or "established," as well as the time spent providing medically necessary level 5 E/M services. Once the total time spent is appropriately documented, the physicians/QHPs should verify if the patient's payer is Medicare or a private payer following Medicare guidelines.
* If the answer is yes, the physicians/QHPs should compare the total time documented with the maximum time built into 99205 (74 minutes) and into 99215 (54 minutes). If the total time documented exceeds these upper limits by 15 minutes, then the physicians/QHPs should report G2212 in addition to 99205 or 99215. Examples:
If the patient is new and the documented medically necessary level 5 E/M time was 75 minutes, the physicians/QHPs should only report 99205.
If the patient is new and the documented medically necessary level 5 E/M time was 80 minutes, the physicians/QHPs should only report 99205.
If the patient is new and the documented medically necessary level 5 E/M time was 90 minutes, the physicians/QHPs should report 99205 plus one unit of G2212.
Explanation: Medicare, and private payers who follow Medicare guidelines, will only pay for prolonged E/M services that exceed the upper limit of the time in the code description. For 99205, whose code description includes 60 to 74 minutes, the prolonged service time must exceed the 74 minutes by 15 minutes. Therefore, 99205 should be reported with one unit of G2212 when the physicians/QHPs document time between 89 and 103 minutes.
For 99215, whose code description includes 40 to 54 minutes, the prolonged time must exceed the 54 minutes by 15 minutes. Therefore, 99215 should be reported with one unit of G2212 when the physicians/QHPs document time between 69 and 83 minutes.
* If the answer is no, the physicians/QHPs should compare the total time documented with the minimum time built into 99205 (60 minutes) and 99215 (40 minutes). If the total time documented exceeds these lower limits by 15 minutes, the physicians/QHPs should report 99417 in addition to 99205 or 99215. Examples:
If the patient is new and the documented medically necessary level 5 E/M was 50 minutes, the physicians/QHPs should only report 99205.
If the patient is new and the documented medically necessary level 5 E/M time was 80 minutes, the physicians/QHPs should report 99205 plus one unit of 99417.
If the patient is new and the documented medically necessary level 5 E/M time was 90 minutes, the physicians/QHPs should report 99205 plus two units of 99417.
Explanation: Private payers will pay for prolonged E/M services that exceed the lower time limit specified in the code description. For 99205, whose code description includes 60 to 74 minutes, the prolonged service time must exceed the 60 minutes by 15 minutes. Therefore, 99205 should be reported to private payers with 1 unit of 99417 when the physicians/QHPs document time between 75 and 89 minutes.
For 99215, whose code description includes 40 to 54 minutes, the prolonged time must exceed the 40 minutes by 15 minutes. Therefore, 99215 should be reported to private payers with 1 unit of 99417 when the physicians/QHPs document time between 55 and 69 minutes.
Q: If physicians/QHPs provide a level 5 E/M service for a patient and perform additional work during the next week, such as calling the patient with test results, can the physicians/QHPs report that work with a prolonged service code?
A: No, the physicians/QHPs can only report a prolonged service code based on the work performed on the actual date of the level 5 E/M service.
Q: When determining if a prolonged service code can be reported, can the time spent by other clinical staff be included?
A: No, clinical staff time does not count toward prolonged services reported with 99417 and G2212. Time spent on the date of the encounter only includes the face-to-face and non-face-to-face time personally spent by the physician/QHP. For a complete list of the physician/QHP activities that can be counted in the time spent on the date of the encounter, see the Time section under the Guidelines Common to All E/M Services in the CPT 2022 codebook.
Q: If the E/M service does not meet the level 5 E/M qualifications but requires prolonged services, is it correct to assume that the physician/QHP should not report the prolonged service codes 99417 and G2212?
A: You are correct. Physicians/QHPs must first perform and document a level 5 E/M service that qualifies for either 99205 or 99215. Then, if the prolonged services time qualifications are met and documented, the physicians/QHPs may report either 99417 or G2212, depending on the payer.
Q: Should physicians/QHPs report the prolonged services code 99417 or G2212 if they exceeded the level 5 E/M minutes requirement, but did not spend a full 15 minutes above the level 5 E/M requirement?
A: No, physicians/QHPs should not report 99417 or G2212 for any additional time increments less than 15 minutes.
Q: Are there medically unlikely edits (MUEs) for codes G2212 and 99417?
A: Yes, MUEs exist for both codes. However, the good news is that the MUEs have recently increased. Prior to July 1, 2022, the MUEs for both 99417 and G2212 allowed four units of prolonged E/M service (60 minutes) per patient on the same day. Effective July 1, 2022, the MUEs for both 99417 and G2212 were increased to six units. That means that physicians/QHPs can report up to an extra 90 minutes of medically necessary prolonged E/M service time per patient per day.