Why Are My Prolonged E/M Service Claims Denied by Medicare?

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Because wound/ulcer management physicians and other qualified healthcare professionals (QHPs) are frequently presented with patients who have high risk complicated wounds/ulcers, the time required to conduct initial assessments, to order/perform diagnostic and/or imaging tests, to create/revise a thorough plan of care, etc., often exceeds the time allotted in level 5 new (99205) or established (99215) evaluation and management (E/M) services. For many years, many medical specialties complained about this issue and requested codes for prolonged E/M services. Finally, in 2021, new codes were created for prolonged E/M services performed on the date of office or other outpatient services.

The real-life consultation below describes what happened when a physician who provides wound/ulcer management in her office and in a hospital owned outpatient wound/ulcer management provider-based department inappropriately reported the new prolonged E/M services code.

Scenario

Dr. A, a wound/ulcer management specialist, focuses on assessing the underlying cause(s) of hard-to-heal wounds and chronic ulcers, diagnosing based on test and imaging results, and creating a plan of care based on all the collected data. This type of in-depth evaluation and management typically requires more time than is allotted in level 5 new or established E/M codes. Therefore, in 2021 Dr. A was thrilled when her coder informed her that the American Medical Association created a new prolonged service code, 99417.

The coder and Dr. A carefully reviewed the code description of 99417 as well as the information about the new code in the CPT^®1 2021 codebook and the CPT^® Changes 2021 An Insider’s View book. Once they understood how to calculate the prolonged services time, Dr. A. began to document the time she spent providing prolonged E/M services and her coder began reporting 99417 on claims.

Unfortunately, the biller did not monitor if the claims reported with 99417 were paid. A few weeks ago, Dr. A compared her 2021 revenue to her 2020 revenue. Because she was able to bill for prolonged E/M services in 2021, Dr. A expected that her 2021 revenue would exceed her 2020 revenue. To her surprise, that did not happen.

That is when Dr. A contacted this consultant.

Facts to Consider

·      The American Medical Association (AMA) created 99417, which has the following description: Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes of total (List separately in addition to codes 99205, 99215 for office or other outpatient evaluation and management services). NOTE: The AMA instructs physicians/QHPs to start counting the 15 minutes of prolonged services at the minimum time threshold of 99205/99215.

·      The Centers for Medicare and Medicaid Services (CMS) did not agree with AMA’s method to start counting the 15 minutes of prolonged at the minimum time threshold of 99205/99215. Instead, the CMS believes physicians/QHPs should start counting the 15 minutes of prolonged services after the maximum time threshold of 99205/99215. Therefore, the CMS created their own new prolonged E/M service code G2212, which has the following description: 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

·      Physicians/QHPs, who perform prolonged E/M services, should report G2212 to Medicare and any other payers who are following the CMS’ guidelines for counting the 15 minutes of prolonged services.

·      Physicians/QHPs, who perform prolonged E/M services, should report 99417 to private payers who are following the AMA’s guidelines for counting the 15 minutes of prolonged services.

Consultation

First, I verified that all prolonged E/M services were coded as 99417 on claims submitted to all payers.

Second, I requested the biller to review each claim that was coded with 99417 and 1) to list which payers recognized and paid for 99417 and 2) to list which payers did not recognize and did not pay for 99417. When I received the 2 lists, I learned that 95% of the claims were submitted to Dr. A’s Part B Medicare Administrative Contractor (MAC). As expected, everyone of those claims were not paid because Medicare does not recognize 99417. That also explained why Dr. A did not experience the increased revenue that she expected. Most of the private payers did recognize and pay for 99417, but the small percentage of claims processed by these payers did not significantly increase Dr. A’s revenue.

Third, I educated Dr. A, her coder, and her biller that prolonged E/M services submitted to their Part B MAC, should be reported with G2212, not 99417. I also recommended that they reopen any claims incorrectly reported with 99417 that are still eligible for reopening. That way, they may recoup some of the revenue for the prolonged E/M services performed and documented.

Fourth, I educated the team that 99417 should only be submitted to payers who are not following Medicare’s guidelines for calculating prolonged services time.

Fifth, we reviewed the list of private payers who recognized and paid Dr. A for 99417. I advised the coders and billers to contact any other contracted private payers and to ask them if they recognize and pay for 99417 or G2212.

Finally, we discussed the importance of reviewing new, changed, and deleted codes from both the AMA and CMS. One should not assume that CMS will always recognize, cover, and pay for a code created by the AMA. Once in a while CMS creates its own code when it does not agree with an AMA code description. Therefore, Dr. A, her coder, and her biller should implement a process for reviewing code updates from AMA and CMS.

Summary

Wound/ulcer management physicians/QHPs now have the opportunity to report prolonged E/M services when needed to manage complicated patients. For claims processed by Part B MACs, they should start counting the 15 minutes of prolonged services after the maximum time threshold of 99205/99215 and should report G2212. For claims processed by private payers who are not following Medicare’s counting methodology for prolonged services, they should report 99417 and start counting the 15 minutes of prolonged services after the minimum time threshold of 99205/99215. To accomplish this, the coders and billers should research which prolonged E/M service code each of their contracted private payers recognize and pay.

Kathleen D. Schaum oversees her own consulting business and is a founding member of the Today’s Wound Clinic editorial advisory board. She can be reached for consultation and questions at kathleendschaum@bellsouth.net.

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Reference
 
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