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Try CasePilotThis 2025 guide covers the official definition, AMA vs. Medicare rules, documentation needs, and real-world clinical examples.
According to the AMA, CPT 99417 is defined as:
“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.”
Eligible Codes: In 2025, 99417 can be reported with the highest-level office/outpatient codes:
To bill 99417, you must meet specific time thresholds. The AMA rule states you cannot report prolonged services until 15 minutes beyond the typical time of the primary code has elapsed.
| Service Code | Patient Type | CPT Typical Time | Time to Bill 99417 (1st Unit) | AMA Range |
|---|---|---|---|---|
| 99215 | Established Patient | 40 minutes | 55 minutes (40 + 15) | 55–69 mins = 1 unit |
| 99205 | New Patient | 60 minutes | 75 minutes (60 + 15) | 75–89 mins = 1 unit |
Note: You must complete the full 15-minute increment. At 69 minutes for an established patient, you bill 1 unit. At 70 minutes, you enter the second increment (70–84 minutes) and can bill 2 units.
Critical Difference: Medicare does not recognize 99417. Instead, CMS created HCPCS code G2212. Medicare requires exceeding the maximum time of the base code range by 15 minutes, making their threshold higher than the AMA’s.
For example, a 65-minute established patient visit qualifies for 99417 (Commercial) but does not qualify for G2212 (Medicare) .
| Service | Commercial (99417) Threshold | Medicare (G2212) Threshold |
|---|---|---|
| 99215 | 55 minutes | 69 minutes (54 max + 15) |
| 99205 | 75 minutes | 89 minutes (74 max + 15) |
Key Payer Rule:
Accurate documentation is critical. Payers audit these codes to ensure the time was actually spent and medically necessary.
Scenario 1: Established Patient (65 Mins) – Commercial vs. Medicare Patient with multiple chronic conditions. Total time: 65 minutes. Commercial: Bill 99215 + 99417 x 1 (Exceeds 55 min). Medicare: Bill 99215 only. (Does not meet 69 min threshold). Scenario 2: New Patient Consult (100 Mins) Complex new patient requiring extensive record review. Total time: 100 minutes. Commercial: Bill 99205 + 99417 x 2 (100 mins covers the 90-104 min range). Medicare: Bill 99205 + G2212 x 1 (100 mins covers the 89-103 min range).
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| Short Descr | PROLNG OP E/M EACH 15 MIN | Medium Descr | PROLONGED OUTPATIENT E/M SERVICE EACH 15 MINUTES | Long Descr | 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 (List separately in addition to the code of the outpatient Evaluation and Management service) | Status Code | Not Valid for Medicare Purposes | Global Days | ZZZ - Code Related to Another Service | PC/TC Indicator (26, TC) | 9 - Not Applicable | Multiple Procedures (51) | 9 - Concept does not apply. | Bilateral Surgery (50) | 9 - Concept does not apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 9 - Concept does not apply. | Co-Surgeons (62) | 9 - Concept does not apply. | Team Surgery (66) | 9 - Concept does not apply. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Non-Covered Service, not paid under OPPS | Type of Service (TOS) | 1 - Medical Care | Berenson-Eggers TOS (BETOS) | none | MUE | 6 |
This is an add-on code that must be used in conjunction with one of these primary codes.
| 99205 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. | 99215 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. | G0463 | Medicare Coverage: Carrier Priced MPFS Status: Statutory exclusion (from MPFS, may be paid under other methodologies) APC J2 Hospital outpatient clinic visit for assessment and management of a patient |
| 25 | Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59. | 95 | Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system. | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | AJ | Clinical social worker | GJ | "opt out" physician or practitioner emergency or urgent service | SA | Nurse practitioner rendering service in collaboration with a physician | 24 | Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period: the physician or other qualified health care professional may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. this circumstance may be reported by adding modifier 24 to the appropriate level of e/m service. | 33 | Preventive services: when the primary purpose of the service is the delivery of an evidence based service in accordance with a us preventive services task force a or b rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. for separately reported services specifically identified as preventive, the modifier should not be used. | 57 | Decision for surgery: an evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of e/m service. | AF | Specialty physician | AH | Clinical psychologist | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CM | At least 80 percent but less than 100 percent impaired, limited or restricted | CR | Catastrophe/disaster related | FS | Split (or shared) evaluation and management visit | GC | This service has been performed in part by a resident under the direction of a teaching physician | GT | Via interactive audio and video telecommunication systems | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | GW | Service not related to the hospice patient's terminal condition | GZ | Item or service expected to be denied as not reasonable and necessary | KX | Requirements specified in the medical policy have been met | PD | Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days | PT | Colorectal cancer screening test; converted to diagnostic test or other procedure | TD | Rn | TU | Special payment rate, overtime | U6 | Medicaid level of care 6, as defined by each state | UA | Medicaid level of care 10, as defined by each state | X2 | Continuous/focused services: for reporting services by clinicians whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed with no planned endpoint to the relationship; reporting clinician service examples include but are not limited to: a rheumatologist taking care of the patient's rheumatoid arthritis longitudinally but not providing general primary care services | X3 | Episodic/broad services: for reporting services by clinicians who have broad responsibility for the comprehensive needs of the patient that is limited to a defined period and circumstance such as a hospitalization; reporting clinician service examples include but are not limited to the hospitalist's services rendered providing comprehensive and general care to a patient while admitted to the hospital | X4 | Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period |
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Date
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Action
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Notes
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| 2024-01-01 | Changed | Guideline information changed. |
| 2023-01-01 | Changed | Code description changed. |
| 2021-01-01 | Added | Code added. |
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