CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP024

Evaluation and Management Coding - Professional Provider

Governs billing, coding, and reimbursement expectations for professional providers submitting E/M services to Blue Cross Blue Shield of Oklahoma; applies to physicians and other qualified healthcare professionals who bill on CMS 1500 and/or UB04 forms.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyEvaluation and Management Coding - Professional Provider

Policy CodePolicy CPCP024

Change TypeNo material change

Effective DateFeb 23, 2026

Next Review Date

Key ActionDocument time supporting prolonged service codes and do not bill prolonged add-on codes for services under the minimum time increment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

99202-99205, 99212-99215Primary office/outpatient E/M codes

99490, 99491CCM codes

99358-99359, +99415-+99418, G2212Prolonged service codes

-FSSplit/shared modifier

15 minMinimum prolonged increment

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Coverage Criteria

Office/outpatient E/M level selection

Covered when ALL of the following are met:

Level must be selected based on either (1) the level of Medical Decision Making (MDM) or (2) the total time for the E/M services performed on the date of the encounter.

Documentation must include a medically appropriate history and physical exam when performed; the extent of history and/or physical examination is not used to select the E/M level.

To qualify for an MDM level, two of the three MDM elements (number/complexity of problems, amount/complexity of data, risk of complications) must be met or exceeded.

When time is used to select the level, documentation must support the total time (face-to-face and non-face-to-face) personally spent by the physician or other qualified healthcare professional on the date of the encounter.

Time-based selection uses CPT time ranges for office/outpatient E/M codes (see coding thresholds); time is not a descriptive component for emergency department E/M levels.

Chronic Care Management (CCM)

Covered when ALL of the following are met:

CCM codes 99490 and 99491 may be reported only by the single physician or other QHP who provides the care management role for the calendar month.

Member must have 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.

A comprehensive care plan must be established, implemented, revised, or monitored for the member.

99490 reports the first 20 minutes of clinical staff time directed by a physician or other QHP per calendar month and may be reported only once per calendar month; services less than 20 minutes in a calendar month are not separately reported.

99491 reports the first 30 minutes personally by the physician or other QHP per calendar month and may be reported only once per calendar month.

Prolonged services

Covered when the following billing and documentation conditions are met:

Prolonged service codes 99358/99359 may be billed for prolonged non-face-to-face services on a date other than the face-to-face E/M but should not be billed on the same date as typical office/outpatient E/M codes (99202-99205/99212-99215).

+99415 and +99416 report prolonged clinical staff face-to-face time in the office/outpatient setting under direct supervision of a physician or QHP; these are billed in conjunction with designated E/M services and should not be billed with +99417.

+99417 (office/outpatient) and +99418 (inpatient/observation) are add-on codes to report prolonged total time provided by the physician or QHP on the date of the E/M service; documentation must support the time billed and services under 15 minutes should not be billed with these codes.

Time spent on separately billed services other than the E/M service should not be counted toward prolonged service time; total prolonged time may be noncontinuous but must be documented.

Split/shared and brief visits

Guidance and required documentation:

For split/shared visits, when time is used to select the level the physician and other QHPs combine only distinct time personally spent on the date of the encounter to define total time; if prolonged time occurs, submit appropriate prolonged service code(s).

Include modifier -FS on claims to identify split/shared visits; documentation must identify both providers who performed the visit and include the date and signature of the provider who provided the substantive portion.

CPT code 99211 is used for basic or short established patient encounters or supervision of clinical staff performing face-to-face services and may be reported when physician/QHP presence is not required.

Prolonged service billing criteria

Billing rules and mutually exclusive relationships (must follow ALL stated rules):

+99417 and G2212 cannot be submitted together for the same date of service.

For Medicare billing, use G2212 instead of +99417 per industry guidance; for non‑Medicare either G2212 or +99417 may be accepted when billed appropriately.

Services rendered less than 15 minutes should not be billed with +99417, +99418, or G2212; minimum increment is 15 minutes.

Time spent rendering separately billed services other than the E/M or psychotherapy service(s) is not counted toward prolonged service time.

+99417 should not be billed with 99415, 99416, 99358, or 99359 on the same date; similarly G2212 should not be reported with 99358, 99359, 99415, or 99416.

Examples

Coding and Billing Codes

Office/outpatient E/MCPTCovered

99202-99205	Office/outpatient new patient E/M codes with associated times
99212-99215	Office/outpatient established patient E/M codes with associated times

Chronic Care ManagementCPTCovered

99490	Chronic care management first 20 minutes of clinical staff time per calendar month
99491	CCM first 30 minutes personally by physician or other QHP per calendar month

Prolonged servicesmixedCovered

99358	Prolonged service before/after direct patient care (non-face-to-face)
99359	Add-on for each additional 30 minutes to 99358
+99415	Prolonged clinical staff service first hour (office/outpatient)
+99416	Each additional 30 minutes for +99415
+99417	Add-on for each additional 15 minutes beyond highest-level primary E/M (office/outpatient)
+99418	Add-on for prolonged time on inpatient E/M
G2212	Medicare HCPCS equivalent to +99417 (use G2212 for Medicare billing)

Critical careCPTCovered

99291-99292

Critical care codes (first hour and additional 30-minute increments)

Brief established patient visitCPTCovered

99211

Brief office visit or supervision of clinical staff for established patient

Prolonged service and related codesmixed

+99417	Prolonged office/outpatient E/M each additional 15 minutes
+99418	Prolonged inpatient/observation E/M each additional 15 minutes
G2212	Prolonged office/outpatient E/M each additional 15 minutes (HCPCS)
99358	Prolonged service without direct patient contact, first hour
99359	Prolonged service without contact add-on (each additional time unit)
+99415	Prolonged clinical staff service first hour (office/outpatient)
+99416	Prolonged clinical staff service each additional 30 minutes

Time thresholds for office/outpatient E/M codes

99202 (New)15-29 minutes

99203 (New)30-44 minutes

99204 (New)45-59 minutes

99205 (New)60-74 minutes

99212 (Established)10-19 minutes

99213 (Established)20-29 minutes

99214 (Established)

Provider Actions and Documentation Requirements

Documentation Required

Documentation and claim review — provide records on request

Providers may be asked to submit medical records and itemized bills to validate site of service, level of care, and services billed; claims are subject to code edit protocols and review against plan documents, provider contracts, policies and coding software logic.

Submit medical records and itemized bills upon request to support billed services.
Ensure claims use valid code combinations and adhere to industry coding guidelines and plan/provider contract terms.
Be prepared for claim review that may evaluate history, exam, MDM complexity, and documentation supporting the billed level of service.

Billing Rule

Split/shared visit billing — use -FS and document providers & substantive portion

Definitions

Established Patient

DefinitionEstablished Patient: member who has received professional services from the physician or other Qualified Healthcare Professional or another physician or other QHP of the exact same specialty and subspecialty who belong to the same group practice, within the last three years.

Same specialty/subspecialty and groupMust be from the exact same specialty and subspecialty and belong to the same group practice

TimeframeWithin the last three years

New Patient

DefinitionNew Patient: member who has not received any professional services from the physician or other Qualified Healthcare Professional or another physician or other QHP of the exact same specialty and subspecialty who belong to the same group practice, within the last three years.

Scope

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyEvaluation and Management Coding - Professional Provider

Policy CodePolicy CPCP024

Change TypeNo material change

Effective DateFeb 23, 2026

Next Review Date

Key ActionDocument time supporting prolonged service codes and do not bill prolonged add-on codes for services under the minimum time increment.

SourceLink

On This Page

+99417 billed in conjunction with primary office/outpatient E/M codes such as 99205 or 99215 as add-on time beyond the primary service.

+99418 billed in conjunction with inpatient E/M codes such as 99223 or 99233 for each 15-minute increment of prolonged inpatient/observation E/M time.

99215 (Established)40-54 minutes

CCM monthly reporting frequency

99490Report for first 20 minutes of clinical staff time per calendar month; may be reported only once per calendar month

99491Report for first 30 minutes personally by physician or other QHP per calendar month; may be reported only once per calendar month

Reporting limitEach CCM code (99490, 99491) may be reported only once during the calendar month

Minimum billable prolonged time increment

Minimum increment15 minutes — services rendered less than 15 minutes should not be billed with +99417, +99418, or G2212

+99417 / G2212 rule+99417 and G2212 cannot be submitted together; for Medicare use G2212 instead of +99417

DocumentationDocumentation should support the time for each prolonged code billed

When billing split/shared visits include modifier -FS and document both providers and who performed the substantive portion; if time is used for level selection, combine only distinct time personally spent by the physician and other QHP and document the total time on the date of encounter.

Include modifier -FS on claims to identify a split/shared visit.
Document the two providers who performed the visit and include the date and signature of the provider who provided the substantive portion.
If time-based reporting is used, combine only distinct time personally spent by each provider and document the total time used for code selection.

Billing Rule

Prolonged E/M billing — document time and respect 15-minute minimum

Document the time supporting any prolonged service add-on code; do not bill +99417, +99418 or G2212 for services under 15 minutes, and do not count time spent on separately billed services toward prolonged service time.

Ensure documentation supports the prolonged total time billed for each add-on code.
Do not bill +99417 or +99418 (or G2212) for services rendered less than 15 minutes.
Do not submit +99417 and G2212 together for the same service; use G2212 for Medicare billing per industry guidance.
Time spent on separately billed services other than the E/M or psychotherapy service(s) must not be included in prolonged time calculations.

Applies to professional services from same specialty/subspecialty within the same group practice

TimeframeNo services in the prior three years

Qualified Healthcare Professional

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

QualificationsEducation, training, licensure/regulation and facility privileging when applicable

FunctionPerforms and independently reports professional services within scope of practice

Medical Decision Making (MDM)

DefinitionMedical Decision Making (MDM): documentation of complexity by the number and complexity of problems addressed, the amount/complexity of data to be reviewed, and the risk of complications, morbidity, or mortality of patient management.

Components1) Number/complexity of problems; 2) Amount/complexity of data to review (medical records, tests, notes, reports); 3) Risk of complications, morbidity, or mortality

RequirementTo qualify for an MDM level, two of the three elements must be met or exceeded

Prolonged total time

DefinitionProlonged total time: time that is at least 15 minutes beyond the time required to report the highest-level primary service; documentation should support the time billed.

Inclusions/ExclusionsIncludes face-to-face and non-face-to-face time personally spent by physician or QHP on date of service; time spent on separately billed services (other than the E/M or psychotherapy service) is not counted toward prolonged time.

Billing guidanceServices rendered less than 15 minutes should not be billed using +99417 or +99418

Prolonged service without contact

99358/99359Used to report prolonged non–face-to-face services before/after direct patient care; should not be billed on the same date as typical office/outpatient E/M codes (99202-99205/99212-99215)

+99415/+99416Prolonged clinical staff services billed in conjunction with E/M services; should not be billed in conjunction with +99417

Mutual exclusionsG2212/+99417 cannot be submitted together; G2212 not reported with 99358, 99359, 99415, or 99416