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    v1.0.30
    OpenPayerBilling CodesProlonged Clinical Staff Services With Physician or Other Qualified Health Care Professional SupervisionCPT cpt-99416-clinical-staff-time-office-outpatient-em
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    CPT 99416: Clinical Staff Time for Office/Outpatient E/M

    Medicare pays $13 on average nationally for this procedure.

    CPT code 99416 describes additional time that clinical staff spend directly with the patient under a provider’s supervision, billed for each additional 30 minutes provided as part of an office or outpatient evaluation and management service; service type: clinical staff time supporting E/M services, typical site of service: office or outpatient clinic.

    For related coverage guidance, see recent payer policy updates: Percutaneous Electrical Nerve Field Stimulation for Functional Abdominal Pain Disorders, Esophagogastroduodenoscopy (EGD) Coverage Policy, Radiofrequency Therapy for Fecal Incontinence.

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    Clinical & Coding Specifications

    Clinical Context

    A 58-year-old patient with poorly controlled type 2 diabetes presents to an endocrinology outpatient clinic for medication adjustment and diabetes self-management education. The patient arrives for a scheduled office visit with the supervising physician; during the visit the physician bills an E/M service. After the physician-directed portion is complete, clinical staff (a licensed practical nurse and a diabetes educator) spend an additional 45 minutes directly with the patient under the physician’s supervision to provide focused self-care training, blood glucose meter teaching, insulin technique review, and care coordination for home health services. The clinic documents the supervised time in the medical record, times the additional staff contact in 30-minute increments, and appends the appropriate modifier(s) when billing. Typical workflow includes physician evaluation and plan, delegation of patient education to clinical staff, real-time supervision and availability by the physician, documentation of staff time spent directly with the patient, and billing for each additional 30-minute increment of staff time using 99416 when supported by the payer’s policy.

    Related CPT Codes

    CPT CodeDescriptionRelationship to This Procedure
    99213Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutesOften billed by the supervising physician for the primary E/M portion; 99416 is reported for each additional 30 minutes clinical staff time under supervision.
    99214Office or other outpatient visit for the evaluation and management of an established patient, typically 25 minutesUsed for more complex E/M visits; 99416 may be appended for additional supervised staff time beyond the physician encounter.
    99415The clinical staff spends additional time directly with the patient on an office or outpatient E/M service; use for each additional 15 minutes of staff time under provider supervision (if applicable)Alternative or complementary code when payer requires 15-minute increments; documents shorter staff-time increments compared with 99416.
    98960Education and training for patient self-management for initial 2-3 sessions, each 30 minutesDiabetes education provided by clinical staff may be billed when payer allows and may occur alongside 99416 if policies permit separate billing.
    99366Medical team conference with interdisciplinary team, patient and/or family, face-to-face; typically directed by a physician or other qualified health care professionalUsed for multidisciplinary care coordination meetings; related when team conferences occur in coordination with extended staff time under 99416.
    G0108Diabetes outpatient self-management training services, individual, per 30 minutesMedicare-specific diabetes education code that may be reported in conjunction with staff-delivered education sessions instead of or alongside 99416 depending on payer rules.

    Related Modifiers

    8 rows

    ModifierDescriptionWhen to Use
    25CPT modifier 25 indicates that on the same day as another procedure or service, the same physician or other qualified health care professional provided a significant, separately identifiable…- When to apply: Use modifier 25 only on an E/M code to indicate the same provider delivered a significant, separately identifiable E/M service on the same day as another procedure or service — i.e.,…
    59Modifier 59 indicates a distinct procedural service when two procedures that are not normally billed together are clinically and procedurally separate. The CPT definition (as reiterated by CMS)…- Use modifier -59 to report a distinct procedural service when documentation supports that the procedure reported is not normally billed together with another service on the same day because of a…
    22Modifier –22 (Increased Procedural Services) is used when a reported procedure is substantially more extensive than normally required. The CPT Manual and CMS state it may be appended only when the…- When to use: Append modifier -22 to a procedural CPT code when the service performed is substantially more extensive than the usual service described by that code — i.e., the procedure required…
    52Modifier ‑52 (Reduced Services) indicates that a service or procedure was partially reduced or omitted at the provider’s discretion, allowing reporting of the basic procedure number with a qualifier…- Use modifier -52 when a physician or qualified health professional electively reduces or omits part of a procedure or service (for example, performing fewer required views or omitting a portion of…
    54Modifier ‑54 (“Surgical care only”) is appended to a CPT surgical procedure when the reporting surgeon performs the intraoperative (surgical) component but does not furnish the preoperative and/or…- Use modifier -54 when the reporting surgeon provided only the intraoperative (surgical) component of a procedure and preoperative and/or postoperative management has been or will be provided by…
    55Modifier –55 indicates the billing provider furnished only postoperative management for a procedure that has a global surgical period. According to AAPC, this modifier is appended to the same CPT…- Use modifier -55 when billing the same CPT surgical code that has a 10- or 90-day global period and you, as a provider other than the original surgeon, furnished ONLY postoperative management (no…
    62Modifier 62 indicates that two surgeons function as co‑surgeons, each performing distinct parts of the same primary surgical procedure. It is appended to the primary procedure code (and any…- Use modifier -62 when two surgeons act as co‑surgeons (both primary surgeons) on a single definitive primary procedure, each performing distinct parts of the same surgical procedure (append -62 to…
    80CPT® Modifier 80 (Assistant Surgeon) is appended to a surgical CPT code when a physician (MD or DO) provides full, continuous assistance throughout the operative procedure. It is intended only for…- Use CPT Modifier -80 when a physician (MD or DO) serves as an assistant surgeon and provides full, continuous assistance throughout the entire operative procedure; append -80 to the surgical CPT…

    Related Provider Taxonomies

    8 rows

    Taxonomy Code
    207Q00000X
    207R00000X
    207L00000X
    363A00000X
    363LA2200X
    2251S0007X
    1835G0000X
    261QC1800X

    Related ICD-10-CM Codes

    26 rows

    ICD-10-CM CodeDescription
    E03.9Hypothyroidism, unspecified
    E11.9Type 2 diabetes mellitus without complications
    E66.9Obesity, unspecified
    E78.5Hyperlipidemia, unspecified
    F17.210Nicotine dependence, cigarettes, uncomplicated
    F32.9Major depressive disorder, single episode, unspecified
    F33.1Major depressive disorder, recurrent, moderate
    F41.9Anxiety disorder, unspecified
    G43.909Migraine, unspecified, not intractable, without status migrainosus
    H10.9Unspecified conjunctivitis

    Showing 1–10 of 26

    Related Payer Policy Updates

    Specialty: Gastroenterology1 / 3

    10 rows

    PolicyPayerEffective Date
    Percutaneous Electrical Nerve Field Stimulation for Functional Abdominal Pain Disordersbcbsvermont2026-12-01
    Esophagogastroduodenoscopy (EGD) Coverage Policyevicore2026-11-05
    Radiofrequency Therapy for Fecal IncontinenceCigna2026-10-15
    Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD)univerahealthcare2026-10-15
    High-Resolution Anoscopy (HRA)Premera Bluecross2026-10-01
    Gastroesophageal and Gastrointestinal (GI) Services and ProceduresColorado Rocky Mountain Health Plans2026-10-01
    Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver DiseaseOscar Health2026-10-01
    Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant TestingOscar Health2026-10-01
    Pancreatic Enzyme Testing for Acute PancreatitisOscar Health2026-10-01
    Helicobacter pylori TestingOscar Health2026-10-01

    Related Codes

    CPT-99415-ADDITIONAL-CLINICAL-STAFF-TIME-OUTPATIENT-E-M

    CPT 99415: Clinical Staff Time for Office/Outpatient E/M

    Frequently Asked Questions

    References

    1. 1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
    2. 2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
    3. 3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.
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