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Prolonged Services for Labor Management
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Defines Premera Bluecross rules limiting separate billing and reimbursement of prolonged services/prolonged E/M add-on codes when used to represent labor management by providers who do not perform the delivery; applies to professional claims.
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 the coding section to clarify code time reporting details and revised the coding description for G2212.
Clarified that the policy restricts use of prolonged service procedure codes when billed separately or with an E/M code to represent labor management by a provider who does not perform the actual delivery.
Coverage Criteria for Prolonged Services
Coverage criteria for prolonged services in labor management
Covered with criteria — the Plan limits separate reimbursement of prolonged service/prolonged E/M add-on codes when billed to represent labor management.
Prolonged Service and Prolonged E/M Add-on Codes
| 99415 | Prolonged clinical staff services, first hour (add-on); use with specified outpatient E/M codes |
| 99416 | Prolonged clinical staff services, each additional 30 minutes (add-on) |
| 99417 | Prolonged outpatient E/M service(s) each 15 minutes (add-on) |
| 99418 | Prolonged inpatient/observation E/M service(s) each 15 minutes (add-on) |
| 99358 | Prolonged E/M service before/after direct patient care; first hour |
| 99359 | Prolonged E/M each additional 30 minutes (add-on) |
| G2212 | Prolonged office/outpatient E/M each additional 15 minutes (add-on); do not report with certain other prolonged service codes |
| G0316 | Prolonged hospital inpatient/observation E/M each additional 15 minutes (add-on) |
| G0318 | Prolonged home/residence E/M each additional 15 minutes (add-on) |
Billing and Authorization Requirements
Prior authorization / reimbursement restriction for prolonged service codes in labor management
Do not separately bill or expect separate reimbursement for prolonged service or prolonged E/M add-on codes when they are used to represent labor management by a provider who does not perform the delivery; management of labor is considered part of the maternity care delivery codes and is not separately billable. Violations may result in auditing, contractual penalties, or termination of contract.
- The Plan will not separately reimburse billed prolonged services for professional outpatient services or for inpatient services, when billed with an E/M code, to represent labor management when that provider does not deliver the baby. [[source]]
- Management of labor is considered a component of the maternity care delivery codes and is not separately billable. [[source]]
- Policy will be archived for dates of service on or after January 1, 2027; refer to the Maternity Services policy for services on/after that date. [[source]]
- Violations may result in increased auditing, contractual penalties, and/or termination of contract; disciplinary actions determined by the Plan. [[source]]
Definitions and Claim Types
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