Prolonged physician services: Hospital inpatient or observation care services
Beginning January 1, 2023, physicians and non-physician practitioners (NPPs) who provide services to Medicare beneficiaries in a hospital can report prolonged services for hospital inpatient or observation care evaluation and management (E/M) visits using the Medicare-specific HCPCS code G0316. Prolonged services can be reported when time is used to select visit level, and the total practitioner time for the highest-level visit is exceeded by 15 or more minutes for medically reasonable and necessary services. HCPCS code G0316 should be listed separately in addition to CPT codes 99223, 99233, and 99236. You should not report G0316 with other primary services. Prolonged services are not reportable in conjunction with codes for hospital inpatient or observation care discharge day management.
Only physicians and NPPs who provide services to Medicare beneficiaries in a hospital can report these prolonged services. No other provider should bill these services.
Code descriptor
HCPCS code G0316: Prolonged hospital inpatient or observation care evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using 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 99223, 99233, and 99236 for hospital inpatient or observation care evaluation and management services
- Do not report G0316 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416
- Do not report G0316 for any time unit less than 15 minutes
Qualifying time
Drawing on the CPT E/M guidelines, except for critical care visits, the following listing of activities can be counted toward total time for purposes of determining the substantive portion, when performed and whether the activities involve direct patient contact:
- Preparing to see the patient (for example, review of tests)
- 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 (when 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
- Care coordination (not separately reported)
Practitioners cannot count time spent on the following:
- The performance of other services that are reported separately
- Travel
- Teaching that is general and not limited to discussion that is required for the management of a specific patient
Medical review when practitioners use time to select visit level
Our reviewers will use the medical record documentation to objectively determine the medical necessity of the visit and accuracy of the documentation of the time spent (whether documented via a start / stop time or documentation of total time) if time is relied upon to support the E/M visit.
Reporting times
When the practitioner selects visit level using time, the practitioner may report prolonged hospital inpatient or observation care E/M visit time using HCPCS add-on code G0316 (Prolonged hospital inpatient or observation care E/M services). The following table provides reporting examples.
Prolonged hospital inpatient or observation care visit reporting - initial
| CPT / HCPCS code(s) | Total time required for reporting* | Count physician / NPP time spent within this timeframe |
|---|---|---|
| 99223 | 75-89 minutes | Date of visit |
| 99223 x 1 and G0316 x 1 | 90-104 minutes | Date of visit |
| 99223 x 1 and G0316 x 2 | 105-119 minutes | Date of visit |
| 99223 x 1 and G0316 x 3 or more (for each additional 15 minutes) |
120 or more | Date of visit |
Prolonged hospital inpatient or observation care visit reporting - subsequent
| CPT / HCPCS code(s) | Total time required for reporting* | Count physician / NPP time spent within this timeframe |
|---|---|---|
| 99233 | 50-64 minutes | Date of visit |
| 99233 x 1 and G0316 x 1 | 65-79 minutes | Date of visit |
| 99233 x 1 and G0316 x 2 | 80-94 minutes | Date of visit |
| 99233 x 1 and G0316 x 3 or more (for each additional 15 minutes) |
95 or more | Date of visit |
Prolonged hospital inpatient or observation care visit reporting - same-day admission and discharge
| CPT / HCPCS code(s) | Total time required for reporting* | Count physician / NPP time spent within this timeframe |
|---|---|---|
| 99236 | 85-109 minutes | Date of visit to 3 days after |
| 99236 x 1 and G0316 x 1 | 110-124 minutes | Date of visit to 3 days after |
| 99236 x 1 and G0316 x 2 | 125-139 minutes | Date of visit to 3 days after |
| 99236 x 1 and G0316 x 3 or more (for each additional 15 minutes) |
140 minutes or more | Date of visit to 3 days after |
*Total time is the sum of all time, with and without direct patient contact and including prolonged time, spent by the reporting practitioner on the date of service of the visit. Time must be used to select visit level. Prolonged service time can be reported when furnished on any date within the primary visit's surveyed timeframe. Consistent with CPT's approach, we do not assign a frequency limitation.
References