HCPCS G2212: Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by... - JF Part B

In order to fulfill its contractual obligation with CMS, Noridian Healthcare Solutions (Noridian), your Medicare Contractor, performs pre-payment reviews in accordance with CMS direction. CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Medical review assesses submitted documentation to validate provider compliance with Medicare payment rules and regulations, including coverage, coding and billing guidelines.

This is to update providers of the claim review findings for HCPCS G2212 Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact. The results of this focused review are not a reflection on providers' competence as a health care professional or the quality of care provided to patients. Specifically, the results are based on the documentation requested by Medicare and/or your facility's compliance with the required documentation.

The Jurisdiction F, Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS G2212 Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact. The quarterly edit effectiveness results from July 1, 2024, to September 30, 2024, are as follows:

Top Denial Reasons

• The requested records were not received
• The documentation submitted supported the key elements and/or reasonable necessity of a lower level of service.
• The documentation submitted was incomplete and/or insufficient

Educational Resources

• How to Respond to ADR
• Documentation Guidelines for Medicare Services
• Evaluation and Management (E/M)

Education

HCPCS G2212 reports prolonged total time (time with and without direct patient contact combined) that is provided by the physician or other qualified health care professional on the date of an office visit or other outpatient service. This code is assigned only when the code for the primary EM service has been selected based solely on total time, and only after exceeding by 15 minutes the maximum time that is required to report the highest-level service.

Failure to Return Records

The Internet-Only Manual (IOM) addresses timeframes for submission of records for pre-payment reviews in the Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.2.3.2.

"When requesting documentation for prepayment review, the MAC and ZPIC shall notify providers that the requested documentation is to be submitted within 45 calendar days of the request. The reviewer should not grant extensions to providers who need more time to comply with the request. Reviewers shall deny claims for which the requested documentation was not received by day 46."

Incomplete And/or Insufficient Documentation

When additional documentation has been requested to verify compliance with the CPT® code billed and the submitted documentation lacks evidence to support that, the claim will be denied as the documentation submitted was incomplete and/or insufficient. Refer to Internet Only Manual (IOM), Publication (Pub) 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8(C)

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