Prolonged physician services: Office and other outpatient visits

Effective January 1, 2021, CMS created HCPCS code G2212 for prolonged office and outpatient evaluation and management (E/M) visits. HCPCS code G2212 is used for billing Medicare for prolonged office and outpatient E/M visits instead of CPT codes 99358, 99359 or 99417, for dates of service on and after January 1, 2021.

Code descriptor

HCPCS code G2212: 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
• Can bill CPT code 99483 with HCPCS code G2212 for a visit that exceeds the 60-minute timeframe
• Do not report G2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416
• Do not report G2212 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 count 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 or evaluation
• Counseling and educating the patient, family or 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 or 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 office and outpatient E/M visit time using HCPCS add-on code G2212 (Prolonged office / outpatient E/M services). The following table provides reporting examples.

Prolonged office / outpatient E/M visit reporting - new patient

Prolonged office / outpatient E/M visit reporting - established patient

*Total time is the sum of all time, including prolonged time, spent by the reporting practitioner on the date of service of the visit. 

References

• Change request 13064 - CMS IOM updates to Medicare Claims Processing Manual, Chapter 12
• CMS-1734-F revisions to payment policies under the physician fee schedule and other revisions to Part B for CY 2021
• Medicare Learning Network (MLN) Matters article MM12071 - Summary of policies in the calendar year (CY) 2021 Medicare physician fee schedule (MPFS) final rule, telehealth originating site facility fee payment amount and telehealth services list, CT modifier reduction list, and preventive services list
• Cognitive assessment and care plan services