CMS diverges from CPT guidance on time rules for new prolonged code

Providers may need to keep track of two different times when reporting new CPT® add-on code 99XXX for prolonged services in 2021. CMS will not follow the time ranges that the AMA released in its guidelines for office E/M visits and prolonged services, according to the 2021 Medicare Physician Fee Schedule (MPFS) proposed rule.

The proposed add-on code, currently held by placeholder code 99XXX, will be used to report prolonged office or other E/M services that require at least 15 minutes of total time either with or without direct patient contact on the date of the primary E/M service.

If the changes are finalized, beginning January 1, eligible providers will be able to report add-on code 99XXX in conjunction with the revised E/M codes described below. The add-on code may only be used if the primary code was selected based on time alone.

• 99205, office visit for a new patient, which requires a medically appropriate history and/or examination and a high level of medical decision-making [MDM]. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter.
• 99215, office visit for an established patient, which requires a medically appropriate history and/or examination and high level of MDM. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.

CMS notes that the AMA’s times for reporting the 15-minute prolonged service code could result in time being counted twice because they are based on the minimum time for each Level 5 code.

“As a specific example, the time range for CPT code 99215 is 40-54 minutes. If the reporting practitioner spent 55 minutes of time, 14 of those minutes are included in the services described by CPT code 99215. Therefore, only 1 minute should be counted toward the additional 15 minutes,” CMS states in the 2021 MPFS proposed rule.

CMS will base time for the codes on the maximum time for the Level 5 codes. 

The agency is accepting comments on new and revised codes and other MPFS proposals until October 5.