Some ophthalmologists devote an extraordinary amount of time to an eye exam — as much as an hour or more. In such cases, additional reimbursement is available for a prolonged service in excess of the time allocated to 99205 (60 to 74 minutes) or 99215 (40 to 54 minutes). CPT code +99417 and HCPCS code G2212 apply — however, they have different definitions. Neuro-ophthalmologists and low-vision specialists have particular interest in prolonged services. Let’s examine the relevant codes.

USING PHYSICIAN TIME FOR OFFICE VISIT

Effective January 1, 2021, CPT revised the values for physician time spent for office and outpatient E/M services codes 99202 through 99215. Importantly, CPT expanded the activities for counting time to include

• Preparing to see the patient (eg, review of tests and prior exam notes),
• Obtaining and/or reviewing separately obtained history,
• Performing a medically appropriate examination and/or evaluation,
• Counseling and educating the patient/family/caregiver,
• Ordering medications, tests or procedures,
• Referring and communicating with other health-care professionals (not separately reported),
• Documenting clinical information in the electronic or other health record,
• Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver, and
• Care coordination (not separately reported).

For coding purposes, time for these services is the total time on the date of the encounter. It includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health-care professionals on the day of the encounter. It includes time in activities that require the physician or other qualified health-care professional and does not include time in activities normally performed by clinical staff (eg, autorefraction, measuring Snellen acuity, completing patient history questionnaire or patient dilation). Do not count time for separately reported tests ordered or performed and interpreted by the physician (eg, extended ophthalmoscopy, fundus photography, ultrasound or OCT). In the medical record, include a description of how the time was spent (Figure 1).

NEW PROLONGED SERVICE CODES

In extraordinary circumstances, physician time spent for the eye exam may be longer than 60 to 74 minutes for a new patient and 40 to 54 minutes for an established patient. In this situation, CPT directs that each additional 15 minutes of prolonged services on the day of the encounter be reported, along with 99205 or 99215, using the add-on code +99417: “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; every 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services).” This new add-on prolonged services code may only be used with 99205 and 99215; it may not be used with any other office or outpatient code. Figure 2 illustrates how your claim for a new patient will appear. The number of units on the claim for 99417 varies based on the following time ranges (Table 1).

In the Final Rule for the 2021 Medicare Physician Fee Schedule, CMS did not accept +99417, which shows the additional 15 minutes added to the minimum time in the time range (ie, 60 minutes for a new patient, 40 minutes for an established patient). Instead, CMS created a new HCPCS code, G2212, that uses the maximum time for 99205 and 99215 as a starting point for prolonged services (Table 2). The definition of G2212 is “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 (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services). (Do not report G2212 for any time unit less than 15 minutes).”

For Medicare beneficiaries, use the HCPCS code G2212 to report prolonged services instead of +99417. When dealing with other third-party payers, check their policies. For ophthalmologists, coding E/M based on time rather than medical decision making will continue to be unusual. When time is the deciding factor for a visit, it will be helpful to have a reimbursement mechanism for the extra time requirements. RP