Prolonged Service Codes

CMS created HCPCS codes when billing Medicare for prolonged Evaluation and Management (E/M) services which exceeds the maximum time for the highest level (99205, 99215, 99223, etc.) E/M visit in each category by at least 15 minutes on the date of service. CMS prolonged service guidelines are different from the American Medical Association (AMA). Medicare Administrative Contractors (MACs) will process claims per the Internet Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 12, section 30.6.15.

CPT codes 99358, 99359 or 99417 are not valid for Medicare with status indicator "I" on the physician fee schedule.

Procedure Codes

CPT/HCPCS Code(s) Descriptor
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 (list separately in addition to CPT codes 99205, 99215, 99483 for office or other outpatient evaluation and management services)

  • Do not report G2212 on the same date of service as 99415, 99416
  • Do not report G2212 for any time unit less than 15 minutes
G0316

Prolonged hospital inpatient or observation care evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using 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 (list separately in addition to CPT codes 99223, 99233, and 99236 for hospital inpatient or observation care evaluation and management services).

  • Do not report G0316 on the same date of service as other prolonged services for evaluation and management.
  • Do not report G0316 for any time unit less than 15 minutes
G0317

Prolonged nursing facility evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using 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 (list separately in addition to CPT codes 99306, 99310 for nursing facility evaluation and management services).

  • Do not report G0317 on the same date of service as other prolonged services for evaluation and management.
  • Do not report G0317 for any time unit less than 15 minutes
G0318

Prolonged home or residence evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using 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 (list separately in addition to CPT codes 99345, 99350 for home or residence evaluation and management services).

  • Do not report G0318 on the same date of service as other prolonged services for evaluation and management.
  • Do not report G0318 for any time unit less than 15 minutes
G0513

Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; first 30 minutes (list separately in addition to code for preventive service)

  • Coinsurance and deductible are waived
G0514

Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (list separately in addition to code G0513 for additional 30 minutes of preventive service)

  • Coinsurance and deductible are waived

 

Reporting times

When the time of the reporting practitioner is used to select the office/outpatient E/M visit level, HCPCS code G2212 could be reported when the maximum time for the highest level (level five) office/outpatient E/M visit (99205 or 99215) is exceeded by at least 15 minutes on the date of the service.

Prolonged Office/Outpatient E/M Visit Reporting

CPT/HCPCS Code(s) Total Time Required for Reporting
99205 60-74 minutes
99205 x 1 and G2212 x 1 89-103 minutes
99205 x 1 and G2212 x 2 104-118 minutes
99215 40-54 minutes
99215 x 1 and G2212 x 1 69-83 minutes
99215 x 1 and G2212 x 2 84-98 minutes

 

Other Prolonged Services

CPT/HCPCS Code(s) Time Threshold to Report Prolonged
99223 x 1 and G0316 x 1
Initial inpatient or Observation visit		 90 minutes
99233 x 1 and G0316 x 1
Subsequent inpatient or Observation visit		 65 minutes
99236 x 1 and G0316 x 1
Inpatient or Observation same day admit and discharge		 110 minutes
99238 and 99239
Inpatient or Observation Discharge		 Prolonged service not applicable
Emergency Department Visits Prolonged service not applicable
99306 x 1 and G0317 x 1
Initial Nursing Facility Visit		 95 minutes
99310 x 1 and G0317 x 1
Subsequent Nursing Facility Visit		 85 minutes
99345 x 1 and G0318 x 1
Home or Residence visit, New patient		 140 minutes
99350 x 1 and G0318 x 1
Home or Residence visit, Established patient		 110 minutes
99483 x 1 and G2212 x 1
Cognitive Assessment and Care Planning		 100 minutes

 

  • Total time is the sum of all time, with and without direct patient contact including prolonged time, spent by reporting practitioner on the encounter date of service.
  • Documentation about the duration and content of medically necessary E/M service and prolonged service(s) billed is required in the medical record. The medical record must be appropriately and sufficiently documented by the physician or qualified Non-Physician Practitioner (NPP) to show that the physician or qualified NPP personally furnished the direct face-to-face time with the patient specified in the CPT code definitions.
  • Start and end times, or total time, of the visit should be documented in the medical record along with the date of service.

References

 

Last Updated Dec 09 , 2023