Key tip: The MDM for a 99212 is exactly equivalent to the MDM required for a 99202. Similarly, 99213 and 99203 have the same requirements, 99214 and 99204 have the same requirements, and 99215 and 99205 have the same requirements.
Step 1 – Problem: Select the applicable number and complexity of problems addressed at the encounter.
Step 2 – Data: Select the amount and/or complexity of data to be reviewed and analyzed. Each unique test, order or document contributes to the combination of two or combination of three in Category 1.
Step 3 – Risk: Select the risk of complications and/or morbidity or mortality of patient management.
The new guidelines provide updated definitions of the elements of medical decision making. It is important to understand these definitions to ensure selection of the most appropriate E/M level. A full list of the AMA definitions can be found in the “CPT Evaluation and Management (E/M) Office or Other Outpatient Code and Guideline Changes.”
Split/Shared Visits
In circumstances where the physician and a qualified healthcare professional each perform face-to-face and non-face-to-face work for a visit, the time spent by each is summed for the total time. For example, if a physician spends five minutes of time with an established patient and the nurse practitioner/physician assistant spends 25 minutes on the date of the encounter, the total time of the visit would be 30 minutes and CPT code 99214 (30–39 minutes) would be selected per the new time intervals.
New Prolonged Services CPT Code
New prolonged services CPT codes G2212 or 99417 (with or without direct patient contact) were created to describe a prolonged office and outpatient E/M service of 15 minutes beyond the total time of the primary E/M procedure (either CPT code 99205 or 99215). It can only be reported when the E/M service has been selected based on time alone (not medical decision making) and only after the total time of a level 5 service (either 99205 or 99215) has been exceeded.
There is still a lot of vagueness in billing for the prolonged service CPT codes. The CMS assigned a status indicator of invalid to code 99417 and will only accept Healthcare Common Procedure Coding System G2212 when billing for the prolonged services.
Coding tip: Providers cannot report CPT codes 99417 or G2212 in conjunction with other prolonged service codes. It is important to understand the key coding guidelines, including:
- List G2212/99417 separately in addition to codes 99205/99215 for office or outpatient E/M services;
- Use the prolonged codes G2212/99417 only with level 5 services when time is the contributing factor;
- Do not report G2212/99417 in conjunction with existing prolonged service codes 99354/99355 (face-to-face prolonged care) or 99358/99359 (non-face-to-face prolonged care); and
- Do not report G2212/99417 for any time unit less than 15 minutes.
The ACR encourages practices to verify with individual payers on their billing/coding guidelines for these new codes. Keep in mind, the the Department of Health and Human Services Office of Inspector General (OIG) states, “The necessity of prolonged services are considered to be rare and unusual. The Medicare Claims Processing Manual includes requirements that must be met in order to bill for a prolonged E/M service code (Medicare Claims Processing Manual, Pub. 100-04, Ch. 12, §30.6.15.1).”
