CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prolonged Services reimbursement

Defines when Colorado Rocky Mountain Health Plans (UnitedHealthcare Community Plan) reimburses prolonged services reported with E/M and other companion codes for Medicaid products; applies to services billed on CMS-1500 (and electronic equivalent) for network and non-network providers.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyProlonged Services reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit accurate claims using CPT/CMS coding for services billed on the CMS-1500 or electronic equivalent.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not reimbursed99358-99359

See listAdd-on codes

CMS-1500Form applies

Indiana noted

Related Billing Codes

CPT-99495-TRANSITIONAL-CARE-MANAGEMENT-MODERATE-MDM-14-DAY-VISIT

CPT 99495: Transitional Care Management, Moderate Medical Decision Making

CPT-99490-CHRONIC-CARE-MANAGEMENT-PROVIDER-DIRECTED-20-MIN

CPT 99490: Provider-Directed Chronic Care Management, First 20 Minutes

HCPCS-G0514-PROLONGED-PREVENTIVE-SERVICE-ADDITIONAL-30-MINUTES

HCPCS G0514: Prolonged Preventive Service, Additional 30 Minutes

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

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

HCPCS-G0513-PROLONGED-PREVENTIVE-SERVICE-OFFICE-OUTPATIENT

HCPCS G0513: Prolonged Preventive Service, First 30 Minutes

CPT-99417-OUTPATIENT-EVALUATION-MANAGEMENT-ADDITIONAL-15-MIN

CPT 99417: Outpatient Evaluation and Management, Additional 15 Minutes

CPT-99359-PROLONGED-NON-FACE-TO-FACE-EVALUATION-30-MIN

CPT 99359: Prolonged Non–Face-to-Face Service, Each Additional 30 Minutes

CPT-99484-BEHAVIORAL-HEALTH-CARE-COORDINATION-CLINICAL-STAFF

CPT 99484: Behavioral Health Care Coordination by Clinical Staff

CPT-99416-CLINICAL-STAFF-TIME-OFFICE-OUTPATIENT-EM

CPT 99416: Clinical Staff Time During Office or Outpatient E/M Service

CPT-99496-TRANSITIONAL-CARE-MANAGEMENT-HIGH-COMPLEXITY

CPT 99496: Transitional Care Management, High Complexity

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Prolonged Services — Reimbursement Criteria

Prolonged Services reimbursement criteria

Covered when ALL of the following conditions are met:

Prolonged services are reported in conjunction with an appropriate primary E/M or other primary service code in which time is a factor in determining level of service (per CPT guidelines).

The reported prolonged service time is beyond the typical duration of the primary service on the same date; only time beyond the usual service is counted, even if non-continuous.

Time spent performing separately reportable services must be excluded when calculating prolonged service time (for example, time devoted to CPT 92950 cardiopulmonary resuscitation is not included).

A single date prolonged service totaling less than 30 minutes is not separately reported because that work is considered included in the E/M code.

Prolonged service add-on codes must be reported only with an appropriate primary code (examples include CPT 99354-99357, 99359, 99415-99416, 99437, 99439, G0513, G0514, G2212).

Prolonged Services with Direct Patient Contact (face-to-face) may be reimbursed when the above conditions are met and documentation supports the additional time.

ALL of the following

Not separately reimbursed when reported with CM codes: 99484, 99487, 99489, 99490, 99492-99494, G2058
Not separately reimbursed when reported with TCM codes: 99495, 99496
Policy also references CM code 99417 in this non-reimbursement guidance

Prolonged services for labor and delivery are not separately reimbursable as these services do not have a time component per ACOG guidance.

State-specific exceptions apply: Indiana exempts CPT 99354-99357 from this policy; CPT 99359 and 99415-99416 are not covered for Indiana Medicaid.

Relevant Codes and Coding Rules

Prolonged Services (not separately reimbursed with certain CM/TCM)CPTNot Covered

99358-99359

Prolonged services without direct patient contact (will not be separately reimbursed when reported with specified Care Management or Transitional Care Management codes)

Prolonged service add-on codes (must be reported with appropriate primary code)CPT

99354-99357	Prolonged service add-on codes
99359	Prolonged service add-on code
99415-99416	Prolonged service add-on codes
99437	Prolonged service add-on code
99439	Prolonged service add-on code
G0513	Prolonged service add-on code
G0514	Prolonged service add-on code
G2212	Prolonged service add-on code

Care management and transitional care management codes referencedCPT

99484	Care Management code referenced as companion code
99487	Care Management code referenced as companion code
99489	Care Management code referenced as companion code
99490	Care Management code referenced as companion code
99492-99494	Care Management codes referenced as companion codes
G2058	Care Management HCPCS/HCPCS-like code referenced as companion code
99495	Transitional Care Management code referenced as companion code
99496	Transitional Care Management code referenced as companion code
99417	Care Management/companion code referenced in guidance

State-specific notes (Indiana)CPT

99354-99357	Per Indiana regulations, CPT codes 99354 thru 99357 are exempt from this policy
99359	Per Indiana regulations, CPT code 99359 is not covered for Indiana Medicaid
99415-99416	Per Indiana regulations, CPT codes 99415 through 99416 are not covered for Indiana Medicaid

Prolonged services - add-on grouping (alternative listing)mixed

99354-99357, 99359, 99415-99416, 99437, 99439, G0513, G0514, G2212

Prolonged service add-on codes; must be reported with appropriate primary code

Care management / TCM companion codes (alternative listing)mixed

99484, 99487, 99489, 99490, 99492-99494, G2058, 99495, 99496, 99417

Care management and transitional care management codes cited as companion codes that affect reimbursement for 99358-99359

inv-03: Minimum reportable prolonged time

Minimum reportable prolonged timeA prolonged service of less than 30 minutes total duration on a given date is not separately reported because the work involved is included in the total work of the evaluation and management codes.

Non-continuous time allowedReport only prolonged services beyond the typical duration on a given date even if the physician's time is not continuous.

Exclude separately reportable service timeDo not include time devoted to performing separately reportable services (e.g., CPT 92950 cardiopulmonary resuscitation) when determining prolonged services time.

Claims Submission and Provider Responsibilities

Documentation Required

Claims submission and applicability

You are responsible for submission of accurate claims using CPT/CMS coding. This policy applies to UnitedHealthcare Community Plan Medicaid products and to services reported using the 1500 Health Insurance Claim Form (CMS-1500) or its electronic equivalent, and to all network and non‑network physicians and other qualified health care professionals.

Submit claims that accurately reflect the code(s) that correctly describe the services provided.
This policy governs reimbursement for services billed on CMS-1500 (or electronic equivalent) for UnitedHealthcare Community Plan Medicaid products and applies to all network and non-network providers.

Definitions — Prolonged Services and Provider Identity

inv-05: Prolonged Services with Direct Patient Contact

DefinitionProlonged Services with Direct Patient Contact are when a physician or other qualified health care professional provides prolonged services beyond the usual service in either the inpatient or outpatient setting; Direct Patient Contact is face-to-face and includes additional non-face-to-face services on the patient's floor or unit during the same session.

ReportingThis service is reported in addition to the designated evaluation and management services at any level and any other services provided at the same session as evaluation and management services.

Inclusions/ExclusionsIncludes face-to-face and additional unit/floor non-face-to-face services during same session; does not apply to services without a time component (e.g., labor and delivery management per ACOG).

inv-06: Prolonged Services without Direct Patient Contact

DefinitionProlonged Services without Direct Patient Contact are prolonged services that are neither face-to-face time in the office/outpatient setting nor additional unit/floor time in the hospital or nursing facility during the same session and are beyond the usual service time.