CurrentAnthemPolicy C-08011

Prolonged Services - Professional

Defines Anthem's reimbursement stance and billing requirements for prolonged evaluation and management (E/M) services for commercial plans; applies to professional providers submitting claims to the health plan.

Policy Summary

PayerAnthem

PolicyProlonged Services - Professional

Policy CodePolicy C-08011

Change TypeCoding and documentation updates (material)

Effective Date12/01/2025

Next Review Date

Key ActionProvide documentation detailing the content and duration of prolonged services to support reimbursement consideration.

SourceLink

POLICY UPDATE CHANGES

Updated Policy Section from Coding to Evaluation and Management.

Removed language requiring start and stop times; removed ICD-10 list; updated Related Coding section; removed HCPCS code G2212; removed deleted CPT codes 99354-99357 and added CPT code 99418.

Related coding section updated with new CPT code 99417 and G2212 and reimbursement rules for 99354 and 99355 updated.

C-08011Policy identifier

12/01/2025Effective date

09/03/2025Last review

99358-99359, 99415-99418, 99417Related coding mentions

Generally not separately reimbursableReimbursement stance

Prolonged Services Coverage Criteria

Coverage determination and documentation requirements for prolonged services.

Covered when ALL of the following are met:

Policy applicability
- The health plan allows reimbursement for prolonged services when billed as described in this policy, unless provider, state, or federal contracts and/or mandates indicate otherwise.
- Providers follow CPT coding guidelines when reporting prolonged services.
The prolonged service reported must represent time beyond the E/M service and not be time already included in the primary E/M code (time included in E/M counts toward the primary service).

Policy Summary

PayerAnthem

PolicyProlonged Services - Professional

Policy CodePolicy C-08011

Change TypeCoding and documentation updates (material)

Effective Date12/01/2025

Next Review Date

Key ActionProvide documentation detailing the content and duration of prolonged services to support reimbursement consideration.

SourceLink

On This Page

Code-specific reimbursement rules (must also meet above documentation and coding requirements)

99358 / 99359
- 99358 (Prolonged E/M service before and/or after direct patient care; first hour) — Not separately reimbursable.
- 99359 (Prolonged E/M service before and/or after direct patient care; each additional 30 minutes) — Not separately reimbursurable.
99415 / 99416
- 99415 (Prolonged clinical staff service during an E/M in office; first hour) — Not separately reimbursable.
- 99416 (Prolonged clinical staff service during an E/M in office; each additional 30 minutes) — Not separately reimbursable.
99417
- 99417 (Prolonged outpatient E/M service(s) time beyond required time when primary service selected using total time; each 15 minutes) — Eligible for separate reimbursement when billed in addition to CPT new/established level 5 E/M codes 99205/99215 if the level 5 code was selected using only time as the basis of selection and total time has been exceeded.
99418
- 99418 (Prolonged inpatient or observation E/M service(s) time beyond required time; each 15 minutes) — Not separately reimbursable.

Prolonged Service Codes and Coding Rules

Prolonged service codes and statusCPT

99358	Prolonged E/M service before and/or after direct patient care; first hour
99359	Prolonged E/M service before and/or after direct patient care; each additional 30 minutes
99415	Prolonged clinical staff service (the service beyond the highest time in the range of total time of the service) during an E/M service in the office or outpatient setting, direct patient contact with physician supervision; first hour
99416	Prolonged clinical staff service (the service beyond the highest time in the range of total time of the service) during an E/M service in the office or outpatient setting, direct patient contact with physician supervision; each additional 30 minutes
99417	Prolonged outpatient E/M 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
99418	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

99417 applicability

99417 applicabilityEligible for separate reimbursement when billed in addition to CPT new/established level 5 E/M codes 99205/99215 selected using total time; level 5 E/M must be chosen based on time and total time exceeded

Selection requirementThe level 5 office or other outpatient E/M code must be selected using only time as the basis of selection

Unit of reporting99417 reported for each 15 minutes of total time beyond the primary service

Relationship to primary service99417 is listed separately in addition to the code of the outpatient E/M service

ScopeApplies to office or other outpatient E/M services when criteria met

Documentation, Authorization, and Claim Adjudication

Documentation Required

Documentation and Authorization Requirements

Documentation must support the reporting of prolonged services by sufficiently detailing the content and duration of the provider's service. The health plan requires providers to follow CPT coding guidelines when reporting prolonged services. Prolonged services should not be reported with E/M codes that do not have stated times within their CPT definitions. Correct coding must be used when reporting prolonged services; medical record documentation with content and timeframes are required for consideration of possible reimbursement. Prolonged services will be denied as included in the primary E/M service and will not be eligible for separate reimbursement for typical cases when documentation and CPT criteria are not met. The initial determination of reimbursement is based on claims-data analysis.

Providers must document both content and duration of the service in the medical record.
Follow CPT coding guidelines and only report prolonged services for E/M codes that have stated times.
Maintain and submit supporting medical records/office notes with claim submissions to substantiate billed time.

Denial Risk

Claim Adjudication Actions

Ensure proper billing and submission guidelines are followed, including use of industry-standard CPT, HCPCS, and/or revenue codes that are fully supported in the medical record. Services must meet applicable authorization and medical necessity requirements per the member's benefit plan and state of residence. If appropriate coding/billing guidelines or current reimbursement policies are not followed, the plan may reject or deny the claim, and may recover and/or recoup claim payment. Reimbursement policies may be superseded by provider, state, federal, or CMS mandates.

Claims may be rejected or denied if documentation, coding, or authorization requirements are not met.
The plan may recover or recoup payments when coding/billing guidelines or reimbursement policies are violated.
Authorization and medical necessity requirements must be satisfied in addition to correct coding for reimbursement consideration.

Definitions and Related Coding

Prolonged services — Definition

DefinitionProlonged services are additional time beyond the evaluation and management (E/M) service that may include activities such as history, record review, exam, medical decision making, treatment discussions, and counseling; time spent on these is generally considered part of the E/M service

Documentation requirementDocumentation must sufficiently detail the content and duration of the provider's service to support reporting of prolonged services

CPT guidanceProviders are required to follow CPT coding guidelines when reporting prolonged services; prolonged services should not be reported with E/M codes that do not have stated times

Reimbursement stanceProlonged services will generally be denied as included in the primary E/M and not eligible for separate reimbursement in most typical scenarios when criteria are not met

Related Coding (CPT codes 99358-99359, 99415-99418, 99417)

CPT 99358Prolonged E/M service before and/or after direct patient care; first hour — Not separately reimbursable

CPT 99359Prolonged E/M service before and/or after direct patient care; each additional 30 minutes — Not separately reimbursable

CPT 99415Prolonged clinical staff service during an E/M in office; first hour — Not separately reimbursable

CPT 99416Prolonged clinical staff service during an E/M in office; each additional 30 minutes — Not separately reimbursable

CPT 99417Prolonged outpatient E/M service(s) time beyond required time when primary service selected using total time; each 15 minutes — Eligible for separate reimbursement when billed in addition to CPT new/established level 5 E/M codes 99205/99215 selected using total time and total time exceeded

CPT 99418Prolonged inpatient or observation E/M service(s) time beyond required time; each 15 minutes — Not separately reimbursable