Understanding Billing for Prolonged Services: CPT® 99417 and 99418 vs. HCPCS Codes G2212 and G0316

When it comes to reporting prolonged services for evaluation and management (E/M) visits, outpatient and inpatient/observation, it is essential to differentiate between how commercial payers and the Centers for Medicare and Medicaid Services (CMS) process these services. The American Medical Association (AMA) created two Current Procedural Terminology (CPT®) codes, 99417 and 99418, for use with outpatient and inpatient/observation services, respectively. ​Additionally, CMS created two new Healthcare Common Procedure Coding System (HCPCS) codes, G2212 and G0316, as their response to the AMA’s CPT® codes. 

The two different sets of codes have created a lot of confusion for providers:

1. Trying to understand the differences and similarities in the codes
2. When to select one code set vs. another
3. Understanding the distinctly different criteria to meet thresholds between the code sets

​​This article provides a clear overview to help providers ensure accurate documentation and charge capture, resulting in compliant claims submission.

---

​Background: What Are Prolonged Services? 

​Prolonged services represent additional time spent by a physician or other qualified healthcare professional beyond the usual time required for an outpatient E/M service. These codes are used when care is provided on the same date as the E/M visit and exceeds the total time threshold for the highest level of service. 

The American Medical Association (AMA) established Category I CPT® codes for reporting as add-ons for prolonged outpatient and inpatient/observation E/M services. Additionally, CMS established their own HCPCS codes to be used in place of the CPT® codes for Medicare beneficiaries. It is important providers select the appropriate code for billing based on the payer.   

According to the 2021 outpatient and office-based E/M coding guidelines, prolonged service time is calculated only after reaching the minimum time for CPT® 99205 (new patient) or CPT® 99215 (established patient). In 2023, the AMA also created a prolonged service code for use with inpatient or observation patients as an add-on to the initial and subsequent visits only after reaching the maximum time for CPT® 99223 (initial) or CPT® 99233 (subsequent).   

Interestingly, CY 2023 Medicare claims data show utilization of the AMA CPT® code 99417 was not reported, which speaks to the fact this code is not reported for Medicare beneficiaries. For HCPCS G2212 in CY 2023, the claims data shows it is being utilized by oncologists, just not at the level of utilization that might be expected given the nature of oncology E/M services.

According to CMS, HCPCS G2212 was reported a total of 741,104 times in 2023. Of that total, the breakdown between oncology specialties is below:  

• Hematology/Oncology: 4.3%
• Radiation Oncology: 2.5%
• Medical Oncology: 2.0%
• Nurse Practitioners: 17.2% (highest specialty reporting)

Similar to the prolonged service for outpatient visits, HCPCS G0316 (inpatient/observation visits) does reflect in the CY 2023 claims data utilization by oncology providers, but at a reduced volume. 

According to CMS, HCPCS G0316 was reported a total of 360,144 times in 2023. Of that total, the breakdown between oncology specialties is below:  

• Hematology/Oncology: 2.2%
• Medical Oncology: 0.5%
• Radiation Oncology: 0.1%
• Internal Medicine: 30.7% (highest specialty reporting). 

---

​Prolonged Services for Outpatient Visits:

CPT® 99417: Commercial Payers 

Definition: 
CPT® 99417 is defined as “Prolonged outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure which has been selected using total time on the date of the primary service; each 15 minutes.” 

When to Use: 
99417 should be reported for each 15-minute increment of time spent beyond the time threshold for CPT® 99205 or 99215. Importantly, CPT® guidelines specify that prolonged services start after the minimum time associated with the level 5 E/M code. 

---

​Billing Notes for Commercial Payers:

• Confirm whether the payer follows CPT® guidelines or CMS guidelines (some follow CMS and require adherence to G2212). 
  
• Use CPT® 99417 only if the payer accepts the AMA’s CPT® definition of prolonged services (i.e., starting after the minimum time, not the maximum). 
  
• Ensure documentation clearly supports the total time spent and justifies the additional time billed. 
  

​The following examples from CPT® Assistant (September 2020) review the potential billing scenarios based on time for a visit would support billing the primary E/M service and add-on prolonged services code.

New Patient Example CPT® 99417:

Total Duration of New Patient Office or Other Outpatient Services (use code 99205)	Code(s)
Less than 75 minutes	Prolonged service not reported separately
75-89 minutes	99205 x 1 & 99417 x 1
90-104 minutes	99205 x 1 & 99417 x 2
105 minutes or more	99205 x 1 & 99417 x 3 or more each additional 15 mins

Established Patient Example CPT® 99417: 

Total Duration of Established Patient Office or Other Outpatient Services (use code 99215)	Code(s)
Less than 55 minutes	Prolonged service not reported separately
55-69 minutes	99215 x 1 & 99417 x 1
70-84 minutes	99215 x 1 & 99417 x 2
85 minutes or more	99215 x 1 & 99417 x 3 or more each additional 15 mins

---

​HCPCS G2212: Medicare Beneficiaries 

​Definition: 
HCPCS code G2212 was created by CMS to replace CPT® 99417 for Medicare beneficiaries. It is defined as “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, 99483 for office or other outpatient evaluation and management services.) (Do not report G2212 on the same date of service as codes 99358, 99359, 99415, 99416). (Do not report G2212 for any time unit less than 15 minutes)” 

When to Use: 
Unlike CPT® 99417, G2212 can only be reported after the maximum time for 99205 or 99215 has been exceeded, not the minimum. 

Medicare Requirements: 

• Use G2212 instead of CPT® 99417
• Report only after the full 89 minutes (99205) or 69 minutes (99215) have been met
• Report each additional 15 minutes with G2212

---

​Time Thresholds for G2212 (per CMS):

New Patient Example CPT® G2212: 

Total Duration of New Patient Office or Other Outpatient Services (use code 99205)	Code(s)
Less than 75 minutes	Prolonged service not reported separately
89-103 minutes	99205 x 1 & G2212 x 1
104-118 minutes	99205 x 1 & G2212 x 2
119 minutes or more	99205 x 1 & G2212 x 3 or more each additional 15 mins

Established Patient Example CPT® G2212:

Total Duration of Established Patient Office or Other Outpatient Services (use code 99215)	Code(s)
Less than 55 minutes	Prolonged service not reported separately
69-83 minutes	99215 x 1 & G2212 x 1
84-98 minutes	99215 x 1 & G2212 x 2
99 minutes or more	99215 x 1 & G2212 x 3 or more each additional 15 mins

---

Documentation Requirements:

Whether billing CPT® code 99417 or HCPCS G2212, documentation must: 

• Include the total time spent on the date of service
  
• Detail all medically necessary activities performed during the visit
  
• Support that time was spent face-to-face or on relevant non-face-to-face tasks (such as reviewing results, documentation, and patient communication) 

---

Prolonged Services for Inpatient or Observation Visits

CPT® 99418: Commercial Payers: 

Definition: 
CPT® 99418 is defined as “Prolonged inpatient or observation evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time (List separately in addition to the code of the inpatient and observation Evaluation and Management service).” 

When to Use: 
99418 should be reported for each 15-minute increment of time spent beyond the time threshold for CPT® 99223 or 99233. Importantly, CPT® guidelines specify that prolonged services start after the maximum time associated with the level 5 E/M code, which is different than the outpatient/office-based services thresholds.​

---

​​Billing Notes for Commercial Payers:

• Confirm whether the payer follows CPT® guidelines or CMS guidelines (some follow CMS and require adherence to G0316). 
  
• Use CPT® 99418 only if the payer accepts the AMA’s CPT® definition of prolonged services (i.e., starting after the minimum time, not the maximum). 
  
• Ensure documentation clearly supports the total time spent and justifies the additional time billed. 
  

​The following examples review the potential billing scenarios based on time for a visit that would support billing the primary E/M service and add-on prolonged services code. 

Initial Patient Example CPT® 99418: 

Total Duration of Initial Inpatient or Observation Services (use code 99223)	Code(s)
Less than 90 minutes	Prolonged service not reported separately
90-104 minutes	99223 x 1 & 99418 x 1
105-119 minutes	99223 x 1 & 99418 x 2
120 minutes or more	99223 x 1 & 99418 x 3 or more for each additional 15 minutes

Established Patient Example CPT® 99418:

Total Duration of Subsequent Inpatient or Observation Services (use code 99215)	Code(s)
Less than 65 minutes	Prolonged service not reported separately
65-79 minutes	99223 x 1 & 99418 x 1
80-94 minutes	99223 x 1 & 99418 x 2
95 minutes or more	99223 x 1 & 99418 x 3 or more for each additional 15 minutes

---

HCPCS G0316: Medicare Beneficiaries 

Definition: 
HCPCS code G0316 was created by CMS to replace CPT® 99418 for Medicare beneficiaries. It is defined as “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 health care 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 other prolonged services for evaluation and management codes 99358, 99359, 99418, 99415, 99416). (Do not report G0316 for any time unit less than 15 minutes)” 

When to Use: 
Like CPT® 99418, G0316 can only be reported after the maximum time for 99223 or 99233 has been exceeded by 15 minutes, not the minimum. The time threshold for CMS matches what the AMA has set for prolonged services added to inpatient or observation services.  

Medicare Requirements: 

• Use G0316 instead of CPT® 99418. 
• Report only after the full 90 minutes (99223) or 65 minutes (99233) have been met. 
• Report each additional 15 minutes with G0316. 

---

​Time Thresholds for G0316 (per CMS):

​The time thresholds from the AMA and CMS match for use of prolonged services reporting with inpatient or observation services: 

Initial Patient Example HCPCS G0316: 

Total Duration of Initial Inpatient or Observation Services (use code 99223)	Code(s)
Less than 90 minutes	Prolonged service not reported separately
90-104 minutes	99223 x 1 & G0316 x 1
105-119 minutes	99223 x 1 & G0316 x 2
120 minutes or more	99223 x 1 & G0316 x 3 or more for each additional 15 minutes

Established Patient Example HCPCS G0316: 

Total Duration of Subsequent Inpatient or Observation Services (use code 99215)	Code(s)
Less than 65 minutes	Prolonged service not reported separately
65-79 minutes	99223 x 1 & G0316 x 1
80-94 minutes	99223 x 1 & G0316 x 2
95 minutes or more	99223 x 1 & G0316 x 3 or more for each additional 15 minutes

---

Documentation Requirements:

Whether billing CPT® code 99418 or HCPCS G0316, documentation must: 

• Include the total time spent on the date of service
  
• Detail all medically necessary activities performed during the visit 
  
• Support that time was spent face-to-face or on relevant non-face-to-face tasks (such as reviewing results, documentation, and patient communication) 

---

Key Takeaways 

• Know your payer guidelines. Confirm whether the insurance follows CPT® or CMS guidance. 
• Use CPT® 99417 or 99418 for most commercial payers (if they adopt AMA’s time thresholds). 
• Use G2212 or G0316 for Medicare and any commercial payer that follows CMS guidelines. 
• Accurate documentation of total time is essential to support the billing for prolonged services. Use of statements with “more than” the threshold time will not suffice. There is no support for the actual time spent and if the threshold to start counting prolonged portion was met. 

As always, regularly review payer-specific policies and updates to ensure proper coding and documentation requirements. If in doubt, reach out to RC Billing for guidance.

---

CPT® five-digit codes, nomenclature and other data are copyright 2024 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT®. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein.