AI Solutions for Healthcare

New Prolonged Service Codes Effective Jan 1, 2021

The CPT coding guidelines indicate that the new CPT code, 99417, effective 1/1/2021, is to be used in association with 99215 or 99205.  Due to these changes, it is recommended that you monitor for continued use of 99354 or 99355 for office-based E&M services. Prolonged Service codes (99354 to 99417) are broken out by direct or indirect patient contact, specified clinical settings, along with specified time requirements. The key to correct code selection is the CPT code description. For additional information on the guidelines, please see the reference section at the bottom of this page. As you can see from the code descriptions below, codes 99354 and 99355 should not be reported with office-based E&M services.
  • 99354:  Prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service; first hour (List separately in addition to code for outpatient Evaluation and Management or psychotherapy service, exceptwith office or other outpatient services (99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215)
  • 99355:  Prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service; each additional 30 minutes (List separately in addition to code for prolonged service)
  • 99417:  Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required 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 of total time (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management service)
How to assess this issue using the Codoxo platform: To extract this information across all specialties using the Codoxo platform, the tool of choice would be the query tool:
  • Using the following criteria:
    • Professional Claim Type
    • Claims
    • Date of Service after 1/1/2021
    • Procedure Codes using the Custom Editor feature: (99202 OR 99203 OR 99204 OR 99205 OR 99212 OR 99213 OR 99214 OR 99215) AND(99354 OR 99355)
    • Provider Payment Received minimum, $1
    • This custom join will not work when you select line or aggregate as your criteria
  • To assess individual providers using AI (Artificial Intelligence), use the following detectors:  Frequent Combination, Physician Time, Suspicious Trends or through Schemes.
      • Consider implementing one or all the following to ensure payment accuracy and integrity:
        • Develop a Pre-payment edit to stop payment for the incorrect codes
        • Develop a policy to cover this topic for inclusion in your provider manual
        • Provider education on correctly reporting prolonged office E&M services
        • Recoup the payment differential between 99354 and 99417
        • Audit providers with high utilization of these codes to ensure documentation requirements are met for this code set
References: AMA (American Medical Association) version of the CPT manual pages 40-45.