Professional Services and Time

Documented time plays an important role in choosing many procedures codes. A timed code requires not only the service performed, but also the time spent. The procedure description may include several types of wording.

• Typical time — must meet the midpoint for the time identified 
  • 15 minutes — would need at least 8 minutes 
• At least — must meet the minimum time reported
  • At least 15 minutes 
• Specific time — must meet the minimum time required 
  • 5 to 10 minutes 
• Cumulative time 
  • 30 minutes in a calendar month 

Typical Time
An example of a procedure code with a typical time is 97161 — Physical Therapy Evaluation. This procedure code reports a typical time of 20 minutes. You can choose this procedure code when: 

• You meet the component of the code descriptor
  • You must meet at least the mid-point of 11 minutes of face-to-face time providing the service. 

At Least
You must meet the at least time as listed in the description of the specific procedure code. 

Specific Time
For other professional services, time is a primary factor in choosing the procedure code. Documentation must support you provided the minimum time as listed in the code descriptor. 

Hospital Discharge Management

• 99238 — the first 30 minutes of face-to-face presentation of the discharge management with the patient
• 99239 — more than 30 minutes 
  • Documentation must support the time spent with the patient 

Critical Care

• 99291 — the first 30 to 74 minutes of critical care time 
  • If providing less than 30 minutes, do not use a critical care procedure code 
• 99292 — 30-minute increments of time when more than 30 minutes past the first 74 minutes
  • Must document at least 104 minutes to submit 
  • Must provide a full 30 minutes for each unit of 99292
• To submit critical care, documentation must support
  • The patient was critically ill or injured, with 
  • Acute impairment of one or more vital organ systems and 
  • Probability of imminent life-threatening deterioration of the patient condition 
  • Time spent on the patient 

Cumulative Time
Time for this service must meet a minimum requirement over a calendar month. For example, chronic care management services (CCMS) represent a monthly service. To correctly submit the service, documentation must support time listed in the code provided during the time span.

Prolonged Care 
Providers have many options for reporting prolonged care services. Prolonged care codes exist for preventive services, evaluation and management (E/M) services, and some procedures. 

Medicare rules may differ in how to report these services. For example, CPT® provides several options for prolonged office or other outpatient E/M service. However, the Medicare rules are:

• Use HCPCS code G2212
• Applies only when you use time to choose the level of service 
• Must exceed the time for procedure codes 99205 or 99215 by more than 15 minutes 
  • 99205 time is 60 to 74 minutes
  • Prolonged care when exceeding 89 minutes 
  • 99215 time is 40 to 54 minutes 
  • Prolonged care when exceeding 69 minutes 
• Provided on the same calendar date of the E/M 

Other face-to-face and non-face-to-face prolonged care codes are not correct when the primary code is 99202–99215. 

Medicare provides information on allowed services. For example, Medicare does not pay prolonged care during a period of billing for Chronic Care Management (CCM). 

Medicare added three prolonged care code for services provided January 1, 2023 and after. The codes are: 

• G0316 — Prolonged Inpatient/Observation 
• G0317 — Prolonged Nursing Facility 
• G0318 — Prolonged Home or Residence 

* These codes are only available when using time to choose the level of service. This time used to choose the level of service is only on the date of the encounter. You must meet the time required for the highest level of service for that category. You must exceed the time for the primary code by a full 15 minutes as described by the threshold times above.

Documentation 
Documentation must clearly reflect the time spent providing the service. Documentation must also support the time described.

Resources
Access all the information available. This includes: 

• CPT®
• HCPCS — CPT® or HCPCS instructions do not always agree with Medicare rules and instructions
• National Coverage Determinations (NCD) 
• Local Coverage Determinations (LCD) 
• CMS Medicare Learning Network (MLN) publications 
• CMS Internet-Only Manuals (IOMs) 
• Medicare Administrative Contractors (MACs) 

CMS rules may change. Keep up to date with the latest CMS information. Sign up for the MLN Connects newsletter and your MAC eNews. 

The A/B MAC Provider Outreach & Education (POE) Workgroup developed this document. This joint effort ensures consistent communication and education throughout the nation on a variety of topics. Resources assist the provider and physician community to submit claims correctly and receive proper payment in a timely manner.