October 19, 2023
If using the prolonged service codes, does the level of the E/M service have to meet level 5 criteria?
Yes, the prolonged service codes are only reported with the highest level of office/outpatient visit Evaluation and Management (E/M) code (e.g., 99205, 99215, 99245) when the time requirement has been satisfied. Prolonged services of less than 15 minutes are not separately reported. Prolonged service codes are reported when choosing an E/M code based on time, not Medical Decision Making.
CPT allows reporting add-on code +99417 (Prolonged outpatient evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time) at 15 minutes AFTER the minimum time in the range for the office/outpatient visit E/M code.
CMS has created prolonged service add-on code +G2212 to be used instead of +99417. CMS (Medicare) allows reporting +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) at 15 minutes only AFTER the maximum time in the ranges for the office/outpatient visit E/M code is met.
*This response is based on the best information available as of 10/19/23.