CurrentBlue Cross Blue Shield - New MexicoPolicy CPCP024

Evaluation and Management (E/M) Coding - Professional Provider Services

Defines coding, documentation, and billing guidance for professional providers (physicians and other qualified healthcare professionals) who bill E/M services to Blue Cross Blue Shield New Mexico.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyEvaluation and Management (E/M) Coding - Professional Provider Services

Policy CodePolicy CPCP024

Change TypeNo material change

Effective DateDec 7, 2023

Next Review Date

Key ActionProviders must submit accurate documentation and may be requested to provide medical records and itemized bills to support billed E/M and prolonged service time increments.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

99202-99205, 99212-99215, 99242-99245Key E/M CPT code ranges referenced

99490, 99491Chronic Care Management CPT codes

99358, +99359, +99415, +99417, +99418Prolonged service codes discussed

15 minMinimum increment for +99417/+99418/G2212

Dec 7, 2023Policy effective date

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Evaluation & Management Coverage Criteria

Prolonged services coverage criteria

Prolonged services are covered when documentation supports the additional time and coding rules below. Providers must document total time and clinical details to justify prolonged service reporting.

ALL of the following

Prolonged services are reported only when documentation supports the additional time beyond the primary E/M service or on a date other than the face-to-face E/M encounter as applicable.
Time must be documented as total duration personally spent by the physician, QHP, or clinical staff as specified by the code, and may include non-continuous time when allowed by the code descriptors.
Time spent performing separately reported services (other than the E/M or psychotherapy service) must not be counted toward prolonged service time.
When time is used to select the level of the primary E/M service, prolonged service codes report time beyond the highest-level primary service; services less than the code-defined minimum interval (e.g., <15 minutes for +99417/+99418/G2212) should not be reported.
CPT add-on codes for prolonged clinical staff services (+99415, +99416) require a physician or other QHP to be present to provide direct supervision of clinical staff and are reported in addition to the designated E/M service.
Prolonged service codes billed on dates other than the face-to-face E/M service (99358, +99359) may be billed for non-face-to-face time related to any E/M service and may represent cumulative non-continuous time as described in the code guidance.
Certain prolonged codes are not reportable together: +99417 and G2212 should not be submitted on the same claim; G2212 or +99417 may be accepted for non‑Medicare billing when billed appropriately; +99415/+99416 should not be billed with +99417; 99358/99359 should not be billed on the same date as 99202-99205/99212-99215 and other specified services; +99418 should not be billed on the same date as 90833/90836/90838/99358/99359 (see coding details).
Documentation should support the time for each code billed and the clinical rationale for the prolonged service; lack of adequate documentation may result in denial.

Prolonged services billing guidance

Provider billing and coding notes — follow these rules to reduce risk of denial.

ALL of the following

Use the correct primary and add-on codes per the service setting: 99358/+99359 for non-face-to-face prolonged services on a date other than the E/M encounter; +99415/+99416 for prolonged clinical staff services with direct supervision in office/outpatient; +99417 for physician/QHP prolonged time on the date of an outpatient E/M; +99418 for inpatient/observation prolonged time; G2212 as an alternative to +99417 for Medicare billing considerations.
Do not count time spent on separately reported services toward prolonged service time; do not bill prolonged codes when the documented additional time does not meet the code-specific minimum increments (15 minutes for +99417/+99418/G2212; 1st hour and increments for 99358/+99359; 1st hour and 30-minute increments for +99415/+99416).
Bill add-on prolonged codes only in conjunction with the specified primary E/M codes: e.g., +99417 with 99205, 99215, 99245, 99345, 99350, 99483; +99418 with designated inpatient codes; +99415/+99416 with 99202-99205/99212-99215 as applicable; 99358/99359 are not billed on same date as the listed outpatient E/M codes.

Codes, Increments, and Coding Rules

E/M and related service codesCPTCovered

99202-99205	New patient office/outpatient E/M codes with time descriptors
99212-99215	Established patient office/outpatient E/M codes with time descriptors
99242-99245	Consultation E/M codes
99211	Brief office visit for established patient; supervision of clinical staff
99291-99292	Critical care codes with time-based requirements
99490, 99491	Chronic Care Management codes (monthly reporting rules)
99358, +99359	Prolonged services without direct patient contact
+99415, +99416, +99417, +99418	Prolonged clinical staff or physician prolonged service add-on codes

Prolonged E/M service codesmixedCovered

99358	Prolonged service without direct patient contact (first hour)
99359	Add-on for each additional 30 minutes of prolonged service without direct patient contact
+99415	Prolonged clinical staff service – first hour (office/outpatient) with physician/QHP direct supervision
+99416	Add-on for each additional 30 minutes for prolonged clinical staff service
+99417	Prolonged office/outpatient E/M each additional 15 minutes by physician/QHP on date of E/M
+99418	Prolonged inpatient/observation E/M each additional 15 minutes
G2212	Prolonged office/outpatient E/M each additional 15 minutes (HCPCS alternative to +99417)

MDM vs Time selection

Policy ruleSelect E/M level based on either the level of medical decision making (MDM) OR the total time for E/M services performed on the date of the encounter.

MDM requirementMDM is determined by number/complexity of problems, amount/complexity of data reviewed, and risk of complications; two of the three elements must be met or exceeded to qualify for a specific MDM level.

Time-based selectionWhen time is used, total time on the date of the encounter (see time chart) is used to select the E/M level; document total time if used for code selection.

CCM monthly reporting (99490, 99491)

Reporting frequencyCPT codes 99490 and 99491 may be reported only once per calendar month (each code reported a single time per month).

Documentation, Billing, and Review Requirements

Documentation Required

Documentation and Claims Review Required

Providers are responsible for submission of accurate documentation of services performed. Upon request, providers must submit medical records and itemized bills to validate the site of service, level of care rendered, and that services billed were accurately reported. Medical record documentation must indicate presenting symptoms, diagnoses, treatment plan, and written orders when applicable. Records should include clinical notes, consultation notes, lab/pathology/radiology reports and any other documentation that supports the level of service billed. Documentation may be reviewed to determine history, examination, complexity of medical decision making (MDM), and total services rendered; billing may be adjusted or denied if documentation does not support the level of service.

Medical records and itemized bills may be requested for review.
Documentation must support time for each prolonged service code billed and the level of E/M reported.
Providers should submit claims using valid HIPAA-approved code sets and follow industry coding guidelines (CPT, HCPCS, ICD-10, NDC, UB, CMS/NCCI/CCI, DRG).

Key Definitions

Established Patient

DefinitionEstablished Patient: a member who has received professional services from the physician or other QHP (or another of same specialty/subspecialty in same group practice) within the last three years.

ContextUsed to determine correct E/M patient status for coding and billing purposes.

DocumentationMedical record should reflect prior professional services within three years when classifying as established.

New Patient

DefinitionNew Patient: a member who has not received any professional services from the physician or other QHP (or another of same specialty/subspecialty in same group practice) within the last three years.

Coding implicationUse new patient E/M codes (e.g., 99202-99205) when member meets this definition.

Policy Revision History

2019-10-04policy_created

New policy established.

2020-09-25annual_review

Annual review with disclaimer and verbiage updates.

2020-12-07code_update

Added a new code number to the policy.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyEvaluation and Management (E/M) Coding - Professional Provider Services

Policy CodePolicy CPCP024

Change TypeNo material change

Effective DateDec 7, 2023

Next Review Date

Key ActionProviders must submit accurate documentation and may be requested to provide medical records and itemized bills to support billed E/M and prolonged service time increments.

SourceLink

On This Page

When billing Medicare, use G2212 instead of +99417 per industry guidance; for non‑Medicare, the plan will accept either G2212 or +99417 when billed appropriately.

Ensure documentation specifies total minutes/hours, describes activities performed, and links the prolonged time to the member’s care; include supervisor presence when required for clinical staff codes.

Clinical eligibility

Requires two or more chronic conditions expected to last at least 12 months (or until death) that place the patient at significant risk of death, functional decline, or acute exacerbation/decompensation.

Service elementsA comprehensive care plan must be established, implemented, revised, or monitored; review CPT Codebook for complete list of activities and exclusions.

Prolonged service increment

Minimum additional timeProlonged total time must be at least 15 minutes beyond the time required to report the highest-level primary service to bill +99417 or +99418.

DocumentationDocumentation must support the time for each code billed; services less than 15 minutes should not be billed using +99417 or +99418.

Reference guidanceAdditional guidance available in the AMA CPT Codebook for reporting +99417 and +99418.

Minimum billable increment

15-minute increments+99417, +99418, and G2212 are billed in 15-minute minimum increments (not reported for any time unit less than 15 minutes).

30-minute increments+99359 and +99416 are add-on codes reported in 30-minute increments following their respective initial-hour codes (+99358 and +99415).

Service roundingServices shorter than the minimum increment (15 or 30 minutes as applicable) are not separately reported; documentation must support billed increments.

Non-billable combinations and code pairing restrictions

Mutually exclusive pairingsDo not submit +99417 or +99418 together with +99415/+99416 or with 99358/+99359 on the same date as specified; G2212 and +99417 cannot be submitted together.

Specific prohibitions+99415 should not be billed in conjunction with CPT code 99417; +99416 should not be billed in conjunction with 99417; 99358/99359 should not be billed on same date as certain E/M office codes.

Medicare noteWhen billing Medicare for prolonged office/outpatient time, industry guidance calls for using G2212 instead of +99417; for non‑Medicare the plan accepts either G2212 or +99417 when billed appropriately.

Billing Rule

Billing rules for Prolonged Services (CPT/HCPCS)

Bill prolonged service codes only as described below; do not bill mutually exclusive or conflicting codes on the same date of service. Documentation must support time and service elements for each code billed and time spent on separately reported services should not be counted toward prolonged service time.

99358 and +99359 — Prolonged services on a date other than the face-to-face E/M. Do not bill 99358/+99359 on the same date as 99202-99205/99212-99215 or other conflicting E/M codes.
+99415 and +99416 — Prolonged clinical staff face-to-face time in office/outpatient with direct physician/QHP supervision; report in addition to designated E/M services. Do not bill with 99417.
+99417 and +99418 — Add-on prolonged total time on the date of an E/M service (+99417 office/outpatient; +99418 inpatient/observation). Each add-on represents 15-minute increments beyond the primary service; do not report for durations under 15 minutes. Do not bill +99417/+99418 with codes listed as mutually exclusive (see details).
G2212 — Alternate for +99417 for Medicare billing; for non‑Medicare either G2212 or +99417 may be billed when appropriate. G2212/+99417 and G2212/99358 or 99359, 99415 or 99416 are mutually exclusive — do not submit together on the same date of service.
Time spent on separately reported services other than the E/M or psychotherapy service(s) is not counted toward prolonged service time.

DocumentationMedical record should support that no qualifying professional services occurred within the prior three years.

Qualified Healthcare Professional (QHP)

DefinitionQualified Healthcare Professional (QHP): an individual qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within their scope and independently reports that service.

ScopeIncludes physicians and other clinicians who meet licensure/training and privileging requirements to report professional services.

Use in policyReferences to 'other QHP' throughout the policy denote these qualified individuals when applying coding and supervision rules.

Split or Shared Visits

DefinitionSplit or Shared Visits: visits in which a physician and other QHP both provide face-to-face and non-face-to-face work related to the visit.

Modifier guidanceInclude modifier -FS on claims to identify a split or shared visit and document both providers and the provider who performed the substantive portion (date and signature).

Time combiningWhen time is used for code selection, combine only distinct time personally spent by each provider on the date of the encounter; document total time when used for code selection.

99358 / +99359 (Prolonged non–face-to-face services)

Definition99358: Prolonged service without direct patient contact — first hour on a date other than a face-to-face E/M encounter; +99359: add-on for each additional 30 minutes.

Billing conditionsThese codes may be billed for prolonged non-face-to-face services related to any E/M service on a date other than the face-to-face encounter and may be billed for total non-face-to-face duration even if not continuous.

Exclusions99358/99359 should not be billed on the same date of service as 99202-99205/99212-99215 and other specified E/M codes.

+99415 / +99416 (Prolonged clinical staff services)

Definition+99415: Prolonged clinical staff service — first hour (office/outpatient) with physician/QHP direct supervision; +99416: add-on for each additional 30 minutes.

Supervision requirementA physician or other QHP must be present to provide direct supervision of clinical staff when reporting +99415/+99416.

Billing relationshipThese codes are reported in addition to the designated E/M services and should not be billed in conjunction with +99417.

+99417 / +99418 / G2212 (Prolonged total time add‑on codes)

Definition+99417 / +99418 / G2212: add-on prolonged total time on date of an E/M service billed in 15-minute increments by a physician or QHP; +99417 for office/outpatient, +99418 for inpatient/observation, G2212 as HCPCS alternative for office/outpatient.

Minimum incrementEach code is reported in minimum 15‑minute increments; services less than 15 minutes are not reported with these codes.

Pairing restrictionsThese add-on codes should not be billed with +99415/+99416 or 99358/99359 as specified; G2212 and +99417 cannot be submitted together; Medicare guidance prefers G2212 instead of +99417.

2021-12-23annual_review

Annual review completed.

2023-04-12annual_review

Annual review completed.

2023-12-01content_updateLatest

Added verbiage to the policy.