CMS Issues Corrections to Prolonged Services for “Other” Evaluations and Management (E/M) Visits
On March 15, 2023, the Centers for Medicare and Medicaid Services (CMS) issued corrections to the CY 2023 Medicare Physician Fee Schedule (MPFS). The corrections include updates to prolonged services for “Other” Evaluation and Management (E/M) Visits, specifically the time thresholds which must be met in order to bill for prolonged services.
The previous times indicated by CMS specified significantly higher thresholds for level 3 code for initial or subsequent hospital visits had to meet in order to bill 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 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)).
CMS has a total time of 97 minutes for CPT® 99236, but they round it down to 95 minutes when determining the threshold for billing a prolonged service. The provider would need to spend 15 minutes beyond the 95 minutes, setting a threshold of 110 minutes for this code. The AMA has defined CPT® 99236 with 85 minutes in the definition, 15 minutes beyond this is 100 minutes. Providers must ensure they verify the payer for the respective services to ensure the correct thresholds and codes are supported and billed based on the variances in these prolonged services. The table below reflects the updates by CMS in the correction release:
| Primary E/M Service Prolonged | Prolonged Code | **UPDATED** Time Threshold to Report Prolonged | Count physician/NPP time spent within this time period (surveyed timeframe) |
| Initial IP/Obs. Visit (99223) | G0316 | 90 minutes | Date of visit |
| Subsequent IP/Obs. Visit (99233) | G0316 | 65 minutes | Date of visit |
| IP/Obs. Same-Day Admission/Discharge (99236) | G0316 | 110 minutes | Date of visit to 3 days after |
Initial Inpatient and Observation Care Example HCPCS G0316 **UPDATED by CMS**
| Total Duration of Initial Inpatient and Observation Care (use code 99223) | Code(s) |
| Less than 90 minutes | Not reportedly separately |
| 90 minutes | 99223 x 1 & G0316 x 1 |
| 105 minutes | 99223 x 1 & G0316 x 2 |
| 120 minutes or more | 99223 x 1 & G0316 x 3 or more for each additional 15 minutes |
Subsequent Inpatient and Observation Care Example HCPCS G0316 **UPDATED by CMS**
| Total Duration of Subsequent Inpatient and Observation Care (use code 99233) | Code(s) |
| Less than 65 minutes | Not reportedly separately |
| 65 minutes | 99233 x 1 & G0316 x 1 |
| 80 minutes | 99233 x 1 & G0316 x 2 |
| 95 minutes or more | 99233 x 1 & G0316 x 3 or more for each additional 15 minutes |
