CurrentUnitedHealthcarePolicy N/A

Prolonged Services Reimbursement

Defines when UnitedHealthcare will separately reimburse physicians or other qualified health care professionals for prolonged services reported with E/M or other codes; applies to UnitedHealthcare Commercial and Individual Exchange plans and providers billing on CMS-1500/UB04 as specified.

Policy Summary

PayerUnitedHealthcare

PolicyProlonged Services Reimbursement

Policy CodePolicy N/A

Change TypeVerbiage revisionstemplate transfer

Effective DateN/A

Next Review DateN/A

Key ActionDo not report prolonged services under 30 minutes; prolonged services without direct patient contact (CPT 99358-99359) will not be separately reimbursed when reported with specified Care Management and Transitional Care Management codes.

SourceLink

POLICY UPDATE CHANGES

Updated Policy Verbiage in Application, Overview, Reimbursement Guidelines, Questions and Answers with respect to Other Qualified Health Care Professional.

Transferred content to shared policy template applying to both UnitedHealthcare Commercial and Individual Exchange benefit plans and updated Application section to indicate applicability to both plan types.

CMS-1500claim form applicability

99358-99359non‑face‑to‑face codes

Commercial & Exchangeplan applicability

<30mminimum reportable

Policy Summary

PayerUnitedHealthcare

PolicyProlonged Services Reimbursement

Policy CodePolicy N/A

Change TypeVerbiage revisionstemplate transfer

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Prolonged services reimbursement criteria

UnitedHealthcare reimburses prolonged services when ALL of the following criteria are met and in accordance with CPT/HCPCS and CMS guidance:

ALL of the following

Prolonged services are reimbursable when reported with E/M codes in which time is a factor and only for time beyond the typical duration of the service on a given date.
Physicians or Other Qualified Health Care Professionals should report only prolonged services beyond the typical duration of the service on a given date, even if the time is not continuous.
Time devoted to performing separately reportable services (e.g., cardiopulmonary resuscitation CPT 92950) must be excluded from the calculation of prolonged services time.
A prolonged service of less than 30 minutes total duration on a given date is not separately reported.
Prolonged service add-on codes (for example 99359, 99415-99416, 99437, 99439, G0316-G0318, G0513-G0514, G2212) are add-on codes and should not be reported without the appropriate primary code.
Prolonged services without direct patient contact (CPT 99358-99359) will not be separately reimbursed when reported with specified Care Management codes (e.g., 99484, 99487, 99489, 99490, 99492-99494, 99417) and Transitional Care Management codes (99495, 99496).
Prolonged services are not separately reimbursable with preventive medicine E/M codes (CPT 99381-99397).
Prolonged services for labor and delivery are not separately reimbursable per ACOG guidance for services without a time component.
Modifier 25 may be appended to prolonged services codes when documentation supports a significant, separately identifiable E/M service on the same date of service.
This policy applies to services billed on CMS-1500 or electronic equivalent and to UnitedHealthcare Commercial and Individual Exchange benefit plans and to network and non-network physicians and Other Qualified Health Care Professionals.

Prolonged Services with Direct Patient Contact must be face-to-face between the patient and the physician or Other QHP who provided the initial service; time with office staff or time the patient is unaccompanied by the primary provider cannot be counted.

Relevant Codes and Reporting Thresholds

Prolonged Service / Add-on Codes (CPT & HCPCS)mixed

99415	Prolonged face-to-face services; first hour (add-on)
99416	Prolonged face-to-face services; each additional 30 minutes (add-on)
99437	Caregiver-focused care coordination (add-on/prolonged)
99439	Care management service, per month (add-on/prolonged)
G0316	Prolonged services in the inpatient setting, per 30 minutes (HCPCS add-on)
G0317	Prolonged services in the inpatient setting, each additional 30 minutes (HCPCS add-on)
G0318	Prolonged services in the outpatient setting, per 30 minutes (HCPCS add-on)
G2212	Prolonged office/outpatient E/M or prolonged services; per 30 minutes (HCPCS)
G0513	Prolonged inpatient or observation services beyond the usual service, first hour (HCPCS add-on)
G0514	Prolonged inpatient or observation services beyond the usual service, each additional 30 minutes (HCPCS add-on)

minimum_reportable_duration

Key operational thresholdProlonged service < 30 minutes on a given date is not separately reported.

Billing and Provider Guidance

Billing Rule

Billing rules and denial risks for prolonged services

Do not report prolonged services totaling less than 30 minutes on a given date; such time is considered included in the E/M service and is not separately reportable. Prolonged service add-on codes (e.g., 99359, 99415-99416, 99437, 99439, G0316-G0318, G0513-G0514, G2212) are add-on codes and should not be reported without the appropriate primary code. Prolonged services without direct patient contact (CPT 99358-99359) will not be separately reimbursed when reported with specified Care Management and Transitional Care Management codes.

Exclude time spent performing separately reportable services (for example, CPR CPT 92950) when calculating prolonged services time.
Do not report prolonged services with preventive medicine E/M codes (CPT 99381-99397) — they are not separately reimbursable.
Modifier 25 may be appended to prolonged services codes if documentation supports a significant, separately identifiable E/M service on the same date.

Definitions Related to Prolonged Services

Prolonged Services with Direct Patient Contact

DefinitionProlonged Services with Direct Patient Contact: face-to-face prolonged services beyond the usual service in inpatient or outpatient settings; includes additional non-face-to-face services on the patient’s floor/unit during the same session

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

Provider typeRendered by a physician or Other Qualified Health Care Professional

Prolonged Services without Direct Patient Contact

DefinitionProlonged Services without Direct Patient Contact: prolonged services that are neither face-to-face nor additional unit/floor time during the same E/M session and are beyond the usual service time

CPT codes referencedIncludes CPT codes 99358-99359 which denote services without direct patient contact

Interaction with CM/TCM codesPer policy and CMS/AMA guidance, CPT 99358-99359 will not be separately reimbursed when reported with specified Care Management and Transitional Care Management codes

Same Individual Physician or Other QHP

Definition of 'Same Individual'The Same Individual Physician or Other QHP is the same individual rendering health care services reporting the same Federal Tax Identification number

Applies toPhysicians and Other Qualified Health Care Professionals rendering prolonged services under this policy

Billing implicationServices must be reported under the same Federal Tax Identification number to be considered the same individual for reporting purposes

OpenPayer

Prolonged Services Reimbursement