by Barbara J Cobuzzi
The 2021 Physician Fee Schedule Final Rule was published by CMS on Tuesday December 1, 2020. (https://www.cms.gov/files/document/12120-pfs-final-rule.pdf
) There were not many surprises since we had the Proposed Rule to review during the late summer/early fall. But one new item was introduced as part of the 2021 Outpatient E&M Documentation changes that was not expected and that was the introduction of CMS code G2212, “Prolonged office or other outpatient evaluation and management service(s) beyond maximum required time of the primary procedure which as 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 or 99215 for office or other outpatient evaluation and management services)”.
G2212 replaces AMA CPT code 99417 for Medicare Part B patients. The AMA description of 99417, “Prolonged office or other outpatient evaluation and management service(s) beyond minimum required time of the primary procedure which as been selected using total time requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each additional 15 minutes of total time (list separately in addition to CPT codes 99205 or 99215 for office or other outpatient evaluation and management services)”
Comparing the definitions of G2212 and 99417 it appears at first blush, that they are they are the same. But in reality, one word difference in the two definitions is what sets them apart and makes a significant difference.
First, looking at the CMS definition for G2212, it indicates that prolonged services is supported once the provider has spent 15 minutes more than the “maximum time” for the selected service when time is used to select the office or other outpatient E&M service on the same day as the service. E&M selection based on time for office and outpatient services is based on a range of time. 99205 has a range of 60-74 minutes and 99215 has a range of 40-54 minutes. Using the definition of G2212, prolonged services would be supported as soon as 89 minutes (maximum time of 74 minutes plus 15 minutes) is spent on the date of service by a physician or other qualified provider for a new patient and as soon as 69 minutes (maximum time of 54 minutes plus 15 minutes) is spent by a physician or other qualified provider for an established patient.
The key words in the AMA CPT definition of 99417 is that prolonged services is supported once the provider has spent 15 minutes more than the “minimum time” for the selected service when time is used to select the office or other outpatient E&M service on the same day as the service. This means that instead of having to wait until 89 minutes to qualify for prolonged services based on the AMA’s definition of 99417, the code is supported once 75 minutes is spent on the date of service by a physician or other qualified provider for a new patient. Similarly, 99417 is supported once 55 minutes is spent on the date of service by the physician or other qualified provider for an established patient. CMS did not like this definition, seeing prolonged services being supported only one minute beyond the top end of the time range for the CPT code.
As a result of this difference in interpretation, we will have the 95 and 97 E&M Guidelines for all E&M services that are not an office/outpatient service and then we will have two different guidelines, one for CMS 2021 E&M office and outpatient services and one for AMA 2021 E&M office and outpatient services.
Today, on the CMS Open Door Forum, covering the 2021 PFS Final Rule, I confirmed with CMS that this was the reasoning behind the creation of G2212. The CMS representative confirmed my understanding and complimented me for connecting the dots. You can find the explanation of G2212 on page 286 of the Final Rule at the link listed at the beginning of this article.
With the creation of this code by CMS for Medicare Part B patients, the question comes to mind as to what Medicare Advantage programs are going to expect to be used for prolonged services. Keep in mind that Medicare Advantage plans can make their own reimbursement rules. This means that practices will have to inquire to each Medicare Advantage plan that they work with as to how they expect prolonged services to be coded and be billed. Additionally, do not assume that your state’s Medicaid program follows this CMS code and rule. Practices will have to follow-up with their Medicaid plans, including managed Medicaid plans in order to find out which codes the Medicaid plans expect prolonged services to be used for billing the additional time spent with patients on the date of service by physicians and other qualified providers.
Below is a chart of when prolonged services can be used per the CMS definition for G2212 and the AMA definition of 99417.
