Awareness : Did You Know?

Did You Know? Weekly Educational Series 22

For the Week of February 1, 2016-Two New E/M Codes in 2016 for Prolonged Services

Two New E/M Codes in 2016 for Prolonged Services provided by the Clinical Staff supervised by the Physician or NPP in an Office Setting (POS 11)

  • Codes 99415, 99416 are used when a prolonged evaluation and management (E/M) service is provided in the office or outpatient setting that involves prolonged clinical staff face-to-face time beyond the typical face-to-face time of the E/M service, as stated in the code description.
  • The physician or qualified health care professional (NPP) is present to provide direct supervision of the clinical staff.
  • This service is billed in addition to the designated E/M services and any other services provided at the same session as E/M services.
  • The staff in the physician’s office must be an expense to the physician practice.

Example: Education for a new medication, therapy, or options for care that go far beyond the time spent on the E/M by the physician, but that does not have to be provided by the physician.

Prolonged Services

  • 99415: Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour (List separately in addition to code for outpatient Evaluation and Management service) (Use 99415 in conjunction with 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215) (Do not bill 99415 in conjunction with 99354, 99355)
  • 99416: each additional 30 minutes (List separately in addition to code for prolonged service) (Use 99416 in conjunction with 99415)
  • Prolonged service of less than 45 minutes total duration on a given date is not separately billable because the clinical staff time involved is included in the E/M codes.
  • The typical face-to-face time of the primary service is used in defining when prolonged services time begins.

    For example, prolonged clinical staff services for 99214 begin after 25 minutes, and 99415 is not billed until at least 70 minutes total face-to-face clinical staff time has been performed.

    • When face-to-face time is non-contiguous, use only the face-to-face time provided to the patient by the clinical staff.
    • Code 99416 is used to bill each additional 30 minutes of prolonged clinical staff service beyond the first hour.
    • Code 99416 may also be used to bill the final 15-30 minutes of prolonged service on a given date.
    • Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not billed separately.
    • Codes 99415, 99416 may be reported for no more than two simultaneous patients.
    • Facilities may not bill 99415, 99416.
    • 99415 will be reimbursed by Medicare at $9.77 and 99416 will be reimbursed at $5.70.  Unknown if covered or how much for other third party payers.