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Prolonged Services for Labor Management
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Defines how Premera limits reimbursement for prolonged service procedure codes when billed separately or with E/M codes to represent labor management by providers who do not perform the delivery; applies to Premera Blue Cross, Premera Blue Cross Blue Shield of Alaska, LifeWise Health Plan of Washington, LifeWise Assurance Company, and Premera Blue Cross HMO lines of business and products.
This policy will be archived effective for dates of service on or after January 1, 2027 and refers readers to the Maternity Services policy.
Revised coding section to clarify code time reporting details and updated the coding description for G2212.
Coverage Criteria — Prolonged Services for Labor Management
Prolonged services for labor management — coverage rules
Covered with limitations — the Plan restricts separate reimbursement of prolonged-service/add-on codes when billed to represent labor management by a provider who does not perform the delivery. Exceptions and enforcement are noted below.
Exceptions
- Exceptions to this coverage restriction may be made where a provider or employer group contract dictates otherwise.
Coding — Prolonged Service and Add-on Codes
| +99415 | Prolonged clinical staff services, first hour; add-on to specified outpatient E/M codes |
| +99416 | Prolonged clinical staff services, each additional 30 minutes; add-on to 99415 |
| +99417 | Prolonged outpatient E/M service each 15 minutes; add-on to specified outpatient E/M codes |
| +99418 | Prolonged inpatient or observation E/M each 15 minutes; add-on to specified inpatient/observation E/M codes |
| 99358 | Prolonged E/M before and/or after direct patient care; first hour |
| 99359 | Prolonged E/M each additional 30 minutes; add-on to 99358 |
| G2212 | Prolonged office or other outpatient E/M each additional 15 minutes; add-on to 99205, 99215 |
| G0316 | Prolonged hospital inpatient or observation E/M each additional 15 minutes; add-on to specified inpatient/observation codes |
| G0318 | Prolonged home or residence E/M each additional 15 minutes; add-on to 99345, 99350 |
Provider Actions and Reimbursement Enforcement
Do not separately reimburse prolonged services for labor management by non‑delivering providers
The Plan will not separately reimburse prolonged service procedure codes when billed with an E/M code to represent labor management by a provider who does not perform the actual delivery. Violations may lead to increased auditing and monitoring, contractual penalties, and/or termination of the contract; exceptions may be made where a provider or employer group contract dictates otherwise.
- Do not separately bill prolonged services to represent labor management if the billing provider does not deliver the baby.
- Noncompliance may result in increased auditing/monitoring, performance guarantees, contractual penalties, and/or contract termination.
- Exceptions only when specified by a provider or employer group contract.
Definitions — Labor Management and Add-on Codes
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