CurrentOptumPolicy N/A

Prolonged Services reimbursement

Defines Optum's reimbursement rules for prolonged service add-on codes reported with Evaluation & Management (E/M) and other services for behavioral health benefit plans administered by Optum, affecting providers who submit CMS-1500/837p/837i claims.

Policy Summary

PayerOptum

PolicyProlonged Services reimbursement

Policy CodePolicy N/A

Change TypeAdded codes & guideline updates (April 2026)

Effective DateN/A

Next Review DateN/A

Key ActionReport prolonged service add-on codes only with an appropriate primary E/M code and document start and stop times in the medical record.

SourceLink

POLICY UPDATE CHANGES

Added Prolonged Services Codes 99415 & 99416.

Updates to Reimbursement Guidelines Section, Definitions & Q&As.

Application Section updated (May 2025).

8Prolonged add-on codes referenced

CMS-1500/837p/837iClaims scope

Apr 2026Last update

Separate guidanceCommercial vs Medicare

Prolonged Services Coverage Criteria

Policy Summary

PayerOptum

PolicyProlonged Services reimbursement

Policy CodePolicy N/A

Change TypeAdded codes & guideline updates (April 2026)

Effective DateN/A

Next Review DateN/A

Key ActionReport prolonged service add-on codes only with an appropriate primary E/M code and document start and stop times in the medical record.

SourceLink

On This Page

Prolonged services coverage criteria

Covered when ALL of the following are met:

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Medical record documents start and stop times for the prolonged service episode to determine the appropriate type of prolonged service (face-to-face vs non–face-to-face).

Total E/M time meets or exceeds the specific minute threshold required for the primary E/M code before an add-on prolonged code may be reported.

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For commercial claims, use the applicable CPT prolonged add-on codes (e.g., 99417/99415/99416 as mapped in the coding section); Optum will not reimburse Medicare HCPCS G2212 on commercial members—G2212 is for Medicare only.

For Medicare members, follow Medicare mappings (for example, G2212 with 99205 or 99215 and G0316–G0318 as mapped to specified inpatient/outpatient E/M codes).

CPT codes 99415 and 99416 are not separately reimbursed by Medicare per CMS (these prolonged clinical staff services are not recognized by Medicare for separate reimbursement).

Prolonged Service Add-on Codes & Time Thresholds

Prolonged service add-on codes (Commercial)CPTCovered

99415	Prolonged services (add-on) — commercial guidance; requires documented start/stop times and E/M time threshold per listed E/M codes
99416	Prolonged services (add-on) mapped to certain commercial E/M codes (per chart)
99417	Prolonged services add-on for specific E/M codes (commercial)
99418	Prolonged services add-on for certain inpatient/outpatient prolonged E/M services

Prolonged service add-on codes (Medicare)HCPCS

G2212	Medicare prolonged service add-on for designated E/M codes (Medicare only)
G0316	Medicare prolonged add-on mapped to specific inpatient/outpatient codes
G0317	Medicare prolonged add-on mapped to specific E/M codes
G0318	Medicare prolonged add-on mapped to specific E/M codes

E/M time thresholds per primary code

99202E/M time threshold = 15 minutes; qualifies for prolonged add-on 99415 (commercial)

99203E/M time threshold = 30 minutes; qualifies for prolonged add-on 99415 (commercial)

99204E/M time threshold = 45 minutes; qualifies for prolonged add-on 99415 (commercial)

99205E/M time threshold = 60 minutes; qualifies for prolonged add-on 99415 (commercial) and maps to 99417/ G2212 in other listings

99212 / 99213 / 99214 / 99215E/M time thresholds = 10 / 20 / 30 / 40 minutes respectively; qualifiers for prolonged add-on 99415 (commercial) — 99215 also maps to 99417 (commercial) and G2212 (Medicare)

Selected inpatient/outpatient E/Ms (e.g., 99345, 99350, 99223, 99233, 99236, 99306, 99310)E/M time thresholds range from 45 to 85 minutes per code; prolonged add-on mapping to 99417 or 99418 (commercial) or G0316–G0318 (Medicare) as specified

Billing & Provider Requirements

Billing Rule

Prolonged services billing requirements

Prolonged service add-on codes are add-on only and must be billed with the appropriate primary E/M code; document start and stop times and total E/M time in the medical record so prolonged time can be determined. Do not include time spent performing separately reportable services when calculating prolonged service time.

Report prolonged service add-on codes only with an appropriate primary E/M code.
Document start and stop times and total E/M time in the medical record to determine type and amount of prolonged service.
Exclude time spent performing separately reportable services from prolonged service time.

Billing Rule

Commercial vs Medicare prolonged code use

Optum will not reimburse HCPCS G2212 for commercial members; bill CPT prolonged service code 99417 for commercial claims and reserve G2212 for Medicare members when billed with the appropriate E/M codes (e.g., 99205 or 99215).

Do not bill G2212 for commercial members—Optum will not reimburse it for commercial claims.
Use CPT 99417 for commercial prolonged services when applicable.
Bill G2212 only for Medicare members with the appropriate E/M codes (e.g., 99205 or 99215).

Key Definitions

Same Individual Physician or Other QHP

DefinitionSame Individual Physician or Other QHP means the same individual rendering health care services and reporting the same Federal Tax Identification Number.

ApplicationApplies when determining whether prolonged services billed with an E/M or other service originate from the same rendering individual.

Billing contextUsed to verify that add-on prolonged service codes are reported by the same individual provider (or QHP) associated with the primary E/M under the same tax ID.

Prolonged Services with Direct Patient Contact

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

Setting examplesApplies to hospital, nursing facility, office or outpatient settings when prolonged face‑to‑face time is provided during the same session as the E/M.

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.

ScopeUsed when prolonged non‑face‑to‑face work related to the patient exceeds usual service time and is not reportable as face‑to‑face or unit/floor time.

DocumentationProviders must document start and stop times and the nature of non‑face‑to‑face work to determine appropriate prolonged service coding.