CPT 99417

(2022) CPT 99417 Description, Guidelines, Reimbursement, Modifiers & Examples

CPT 99417 lies in the category of evaluation and management services. This code may be used when the physician spends extra time on an office or other outpatient evaluation and management service than usual time. Use CPT 99417 and G2212 code every 15 minutes if CPT 99205 to 99215 doesn’t complete the time requirement.

CPT 99417 Description

CPT 99417 was created by the American Medical Association (AMA) for 15 minutes of prolonged care performed on the same day as office/outpatient codes 99205 to 99215. Unfortunately, code 99417 has been marked as invalid by Medicare, and a new HCPCS code, G2212, has been created to replace it.

Therefore, if we use CPT 99417, code only with 99205 to 99215, and only when extra time is spent. It is used for both face-to-face and non-face-to-face interactions.

This CPT is used when there is prolonged office and other outpatient evaluation & management service(s) beyond the minimum required time of primary procedure which has been used through total time, requiring full time with or without direct patient interaction beyond the usual service, on date of prior service, every 15 minutes of total time.

It is listed separately in addition to CPT codes 99205 to 99215 for office or other outpatient Evaluation and Management services.

99417 cpt

CPT 99417 Guidelines and Reimbursement

AMA established a prolonged care code in CPT® for 2021 for each additional 15 minutes spent on the same day of service. After the time criteria for 99205 or 99215 are met, this prolonged services code reports total time, both with or without direct patient contact.

Do not include time spent performing other services designated by a CPT® code in the office visit or prolonged care service. For example, to report CPT 99417, the total time of 15 minutes must be met, not the midpoint time.

Only CPT codes 99205 to 99215 can use the new add-on prolonged services code. The CPT 99417 cannot be combined with any other outpatient or office code.

Non-face-to-face extended care codes 99358, 99359, and face-to-face prolonged care codes 99354 and 99355 cannot be reported on the same day as the new add-on code.

To add this additional, comprehensive service code to CPT 99205 – 99215, the entire 15 minutes must be completed.

CPT G2212 is for prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure, as determined by the total time on the date of the initial service; each additional 15 minutes by the provider or other qualified healthcare professional, with or without direct patient exposure (list separately in addition to CPT® codes 99205, 99215 for office or additional outpatient evaluation & management services). 

(G2212 should not be reported on the same day as 99354, 99355, 99358, 99359, 99415, or 99416.) (If the time unit is less than 15 minutes, do not submit G2212). “

CPT codes 99358 and 99359 are used for non-face-to-face long-term care.

Non-face-to-face extended care CPT codes are still valid and chargeable. However, they may not be reported on the same day as 99202—99215. If the billing practitioner performs non-face-to-face prolonged treatment on the day of an office/outpatient visit, add it to the total time for the day.

CPT codes 99354 and 99355 are used for face-to-face long-term care.

These are still valid and chargeable codes, but they must be reported separately from CPT’s 99202–99215. In addition, psychotherapy codes 90837, 90847, office consultation codes 9924199245, domiciliary care codes 99324—99337, home visit codes 99341—99350, and cognitive assessment codes 99483 may be reported for prolonged care services.

Total time duration for new office visit codes:

For less than 75 minutes: This CPT will not be reported separately

For 75-89 minutes: 99205 with 1 unit and CPT 99417 with 1 unit

For 90-104 minutes: 99205 with 1 unit and CPT 99417 with 2 unit

For 105 minutes or more: use 99205 with 1 unit and CPT 99417 with three units or more every 15 minutes.

 Total time duration of established office visit codes:

  For less than 55 minutes: This CPT will not be reported separately

  For 55-69 minutes: Use 99215 with 1 unit and 99417 with 1 unit

  For 70-84 minutes: Use 99215 with 1 unit and 99417 with 2 unit

  For 85 minutes or more: Use 99215 with 1 unit and 99417 with three units or more every 15 minutes.

E/M primary service CPT codes 99205 or 99215 should be selected based on time rather than medical decision-making when the service was 15 minutes or more.

During prolonged E/M service, services must be medically necessary.

In the medical document, the time and content of the evaluation and management code must be documented.

Only use 99205 or 99215 if the highest level office/outpatient E/M visit’s maximum time is surpassed by at least 15 minutes on the service day.

For G2212, a maximum of three units will be allowed; extra units will be rejected by insurance, and additional medical documentation will be required for consideration.

Physician or other qualified health care professional time includes the below-mentioned activities when done:

When preparing to see the patient (e.g., review of tests), obtaining or reviewing separately obtained history, performing a medically appropriate E/M, counseling & educating the patient or its family, ordering for medications, tests, and procedures, referring to other health care professionals (when not separately reported), documenting clinical information in the electronic or another health record, independently interpreting results (not separately reported) and consulting results to the patient or its family, care coordination (not separately reported).

Do not count time spent on the following: the performance of other services reported separately, travel, and teaching that is general and not limited to the discussion required for managing a specific patient.

CPT 99417 replaces other prolonged care codes.

We should not report prolonged service codes 99354, 99355, 99358, and 99359 in addition to a level-five office visit. 99417 CPT replaces 99354 and 99355 (prolonged face-to-face care) and 99358 and 99359 (non-face-to-face prolonged care) for prolonged services with 99205 or 99215.

However, we would still code prolonged service codes 99354/99355 and 99358/99359 for time spent beyond the usual service are included in the following codes:

CPT 90837 is for individual outpatient psychotherapy services, 53+minutes

CPT 90847 is for family psychotherapy with the patient present; 50 minutes are required

CPT 99241–99245 is for office or other outpatient consultation services.

CPT 99324–99327 are for domiciliary, rest home, or custodial care visits.

CPT 99341–99350 is for home services.

CPT 99483 is for cognitive assessment and care plan.

The following guidelines should be applied:

Use CPT 99354 for the first hour of face-to-face prolonged service time.

Use CPT 99355 for each additional 30 minutes of prolonged face-to-face service beyond the first hour.

Use CPT 99358 for the first hour of non-face-to-face prolonged service time.

Use CPT 99359 for each additional 30 minutes of non-face-to-face prolonged service beyond the first hour.

CPT 99417 Modifiers

Only a limited number of modifiers can be used with CPT 99417. Each of the modifiers is explained below in detail. The coder should pay appropriate attention while appending these modifiers with 99417 CPT because their misuse or overuse can lead to comprehensive audits.

If these modifiers are not present in a claim when required, it will not get any reimbursements. Practical examples and applications of modifiers 24, 25, and 57 are described below.

Modifiers (25) Significant, Separately Identifiable E/M Service Provided by the Same Physician or Other QHP on the same day as the procedure or Other Service:

It may be necessary to clarify that on same the day, a procedure or service identified by a CPT code was performed, the patient’s condition entailed a significant, separately identifiable E/M service above and beyond the other service provided & beyond usual preoperative & postoperative care associated with the procedure.

Modifier 24 is appended with 99243 in cases where the encounter for consultation falls in the global period of any surgical procedure.

The global period is categorized as 10 or 90 days as described by the Coding manual, i.e., all the major surgical procedures do have a global period of 90 days, such as lumpectomy, and all the minor surgeries have a global period of 10 days, i.e., I & D. During that global period if the patient receives any consultation the claim will be submitted with modifier 24.

Modifier 57 will be applied with CPT 99417 when the decision to perform surgery was made on the same day of consultation. The same day and day before surgery are included in the global surgical package for minor and major surgical procedures. So, it will not be reimbursed separately and will be considered a part of the surgical procedure.

It has a global period of 0 days. Modifiers 50 (Bilateral Surgery), 51(Multiple Procedure), 80 (Assistant Surgeon), 62 (Co-Surgeon), and 66 (Team Surgery) these modifiers do not apply to CPT 99417.

CPT 99417 Examples

The following examples are when CPT 99417 may be billed.

Example 1

The provider spent 84 minutes of in-office visit with an established patient having high-risk E/M.

A total of 84 minutes were spent. Therefore, CPT 99215 with two units of CPT 99417 should be coded as CPT 99215 covers 54 minutes, and CPT 99417 covers 15 minutes, so two units are appended for CPT 99417.

Example 2

An initial visit was performed with a high-risk E/M service, which took 68 minutes. The service was documented, including the severity of the patient’s condition and the decision to admit the patient to the hospital after an EKG and chest x-ray revealed pneumonia.

We will minus the upper end of the time range for a new patient E/M (99205 – 54 minutes) from the total duration (68-54 = 14 minutes). The leftover 14 minutes will be used to code a prolonged service code.

If the patient’s insurance is Medicare, the 15-minute requirement has not been met, so G2212 is not applicable, and 99215 is reported instead. 

If the patient’s insurance is commercial/private, which is not following Medicare guidelines, then the 14 minutes of prolonged-time qualify for one unit of 99417 CPT & the service would be coded as 99215 with 1 unit and 99417 with 1 unit.

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