Understanding the Medical Billing Complexity of Prolonged Services

Disclaimer: This blog article was written by an AdvancedMD partner. The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of AdvancedMD.

Previously, prolonged services were much easier to apply when the physician documentation supported the service than it is now. It is no longer just reviewing the medical necessity, total time spent and location of service for the visit. We now have to take the patients insurance into consideration as well as the level of service performed. Below are some examples of the changes:

For a new outpatient visit with a level 5 CPT (99205), Medicare requires a minimum total time spent of 89 minutes while the Current Procedural Terminology (CPT) definition states a minimum of 75 minutes. In addition, the prolonged service codes are now different based on the insurance. Medicare requires the use of a Healthcare Common Procedure Coding System (HCPCS) G2212 while other insurance (mostly commercial, but not all) will use the CPT code of 99417. For outpatient visits, prolonged services only apply as an add-on code with CPT 99205 and 99215. Prolonged service codes can no longer be used with any other visit level such as 99204, 99203, 99214, 99213, etc.

There are different prolonged service CPT and HCPCS codes for Assisted Living, Independent Living, Skilled Nursing, Inpatient and/or Observation services as well. The total time spent for some of these services can span one to seven days. Providers would then need to document the total time spent as well as what was performed on each of the days in order to substantiate the prolonged service.

TYRUS Health has spent significant time researching the complexities surrounding the new coding and billing requirements for prolonged services so that you don’t have to. Reach out to us today so that we can provide assistance in navigating these new codes to increase revenue for your practice!