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  • Prolonged Time Versus Visit Complexity Add-on Codes

    Does billing for prolonged services for total physician time, an E/M level 5 and HCPCS code G2212, automatically meet the definition of the complexity add-on code G2111?

    The determination of E/M based on total physician time and the use of the prolonged time add-on code G2212 for Medicare Part B patients (CPT code 99417 for payers that do not follow CMS guidelines) is separate from reporting complexity. Meeting the unique definition of one does not indicate the use of the other. When meeting the definition of both, however, they can be reported together. Prolonged services add-on codes are to be billed only when selecting the level of E/M based on total physician time on the date of the encounter and the designated time for the level 5, new or established exceeds by 15 minutes. or a new patient level 5, CPT code 99205 exceeding 74 minutes and established patient, CPT code 99215, 54 minutes by 15 minutes would prompt prolonged services. Billing based on total physician time and prolonged services are addressed in Fundamentals of Ophthalmic Coding.

    When billing the E/M visit complexity add-on code G2211, chart documentation should support the ongoing care for a single serious condition or complex condition. The determining factor is the long-term relationship between the physician and the patient. It may not be appropriate to be billed every visit. Find current guidance on the Academy's G2211 webpage.