2021 updates for Prolonged services CPT codes

In 2021, there will be two sets of time rules that govern E/M services, one set for office/outpatient codes 99202—99215, and one set for hospital, observation, ED, nursing facility, home, and domiciliary care services. When selecting an office visit code, the clinician may use either the new medical decision making definitions, or total time spent on that date of service.

The Components of E/M code selection will be based on now on the Total time on date of encounter or revised medical decision making (MDM).

History and physical exam as key components are eliminated for the E/M code selection.

The AMA has developed a new CPT code for 15 minutes of prolonged care, done on the same day as office/outpatient codes 99202—99215. They haven’t released that code yet, but it is indicated in CPT and CMS documents as 99XXX.

✚ ● 99XXX  Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has 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 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)

Points to remember while using CPT code 99XXX

• Use 99XXX in conjunction with 99205, 99215
• Do not report 99XXX in conjunction with 99354, 99355, 99358, 99359, 99415, 99416
• Do not report 99XXX for any time unit less than 15 minutes

There will be changes to the rules for use of existing codes 99354, 99355 (face-to-face prolonged care) and codes 99358, 99359 (non-face-to-face prolonged care).

The Changes in CPT codes and the the New CPT code 99XXX will go into effect on January 1, 2021.

This new add-on prolonged services code 99XXX may only be used with 99205 and 99215. It may not be used with any other office/outpatient code. It may not be used on the same date as non-face-to-face prolonged care codes 99358, 99359 or face-to-face prolonged care codes 99354, 99355. And, the time reported must be 15 minutes, not 7.5 minutes. The entire 15 minutes must be done, in order to add on this new, prolonged services code to 99202—99215.

For new patients, CPT says, “For services 75 minutes or longer, see Prolonged Services 99XXX” and for established patients, “For services 55 minutes or longer, see Prolonged Services 99XXX.” Keep in mind their instruction that a full additional 15 minutes must be met for prolonged care.

CMS, in its 2021 Proposed Rule is making it crystal clear that in order to use prolonged care code 99XXX with 99205 or 99215 a clinician must meet the highest time in the range plus 15 minutes. For 99205, the highest time in the range is 74 minutes. In order to report 99XXX with 99205 the clinician must spend 89 (74+15) minutes in direct or non-direct patient care on that date of service. In order to report 99XXX with 99215 the clinician must spend 69 (54+15) minutes in direct or non-direct patient care on that date of service.

References:

https://codingintel.com/