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June 11, 2018

Professional Services Where Time Is a Primary Factor

While time has been included in the definitions of the majority of professional service codes for a number of years now, there is a difference between codes that list "typical" time and codes where time is a primary factor. Typical time noted in the code descriptors are averages that represent a range of times and are designed to assist providers with determining the most appropriate level of code.

In addition to codes that have a "typical" time component, there are a variety of professional codes where time is a primary factor in the code. However, even in cases where time is a primary component, there are differences in the requirements for utilizing these codes. It is important to review the requirements of a code prior to submitting it on a claim. Required time is the necessary time a provider spends rendering the service to the beneficiary, and the appropriate selection of the code includes a firm time basis. There are also codes within the Evaluation & Management code set that use approximate time thresholds, codes that involve a time range and codes that are "add-ons" for additional time spent rendering a service.

When selecting a code based on time, documentation must clearly reflect the time spent providing the service. The following time threshold reference tables include professional service codes from the Evaluation & Management code family with explicit minimum time requirements.

*Please note that the information listed within this document is not an all-inclusive listing of time rated professional services and is for educational purposes only.

Hospital Discharge Management

99238 30 minutes or less
99239 > than 30 minutes

Critical Care

Bill appropriate E/M code; do not bill a critical care code < 30 minutes
99291 30-74 minutes
99292 Each additional 30 minutes

Domiciliary/Rest Home/Home Care Plan Oversight

99339 15-29 minutes
99340 30 minutes or more

Prolonged Services

99354 (not reported separately) < 30 minutes With Direct Patient Contact
99354 30-74 minutes  
99355 Each additional 30 minutes  
99356 1sthour (60 minutes)  
99357 Each additional 30 minutes  
99358 1st hour (60 minutes) Without Direct Patient Contact
99359 Each additional 30 minutes  
99415 (not reported separately) < 45 minutes Prolonged Clinical Staff Services
99415 45-74 minutes  
99416 Each additional 30 minutes  
99360 (not reported separately) < 30 minutes Standby Services
99360 Each 30 minutes  

Case Management Services

99366 (not reported separately) <30 minutes Medical Team Conference with Direct Patient/Family Contact
99366 30 minutes or more  
99367 (not reported separately) < 30 minutes Medical Team Conference without Direct Patient/Family Contact
99367 30 minutes or more  

Care Plan Oversight Services

99374 15-29 minutes
99375 30 minutes or more (add on code to 99374)
99377 15-29 minutes
99378 30 minutes or more (add on code to 99377)
99379 15-29 minutes
99380 30 minutes or more (add on code to 99379)

Preventive Medicine Services

99401 Approximately 15 minutes Individual counseling
99402 Approximately 30 minutes  
99403 Approximately 45 minutes  
99404 Approximately 60 minutes  
99406 >3 minutes and up to 10 minutes Behavioral Change Interventions, Individual
99407 >10 minutes  
99408 (not reported separately) <15 minutes  
99408 15-30 minutes  
99409 >30 minutes  
99411 Approximately 30 minutes Group Counseling
99412 Approximately 60 minutes  

Non Face-to-Face Services

99441 5-10 minutes Telephone Services
99442 11-20 minutes  
99443 21-30 minutes  
99446 5-10 minutes Interprofessional Telephone/Internet Consultations
99447 11-20 minutes  
99448 21-30 minutes  
99449 31 minutes or more  

Inpatient Neonatal Intensive Care Services and Pediatric and Neonatal Critical Care Services

99466 1st 30-74 minutes
99467 Each additional 30 minutes (add on to code 99466)
99485 1st 30 minutes
99486 Each additional 30 minutes (add on to code 99485)

Care Management Services (Chronic Care)

99487 60 minutes (do not report services of <60 minutes)
99489 Each additional 30 minutes (add on code to 99487)
99490 20 minutes or greater

Transitional Care Management Services

99497 Advance care planning, 1st 30 minutes
99498 Each additional 30 minutes (add on code to 99497)

E & M References

2017 AMERICAN MEDICAL ASSOCIATION CURRENT PROCEDURAL TERMINOLOGY (STANDARD EDITION)

This document was developed through the A/B Medicare Administrative Contractor (MAC) Provider Outreach & Education (POE) Collaboration Team. This joint effort ensures consistent communication and education throughout the nation on a variety of topics and will assist the provider and physician community with information necessary to submit claims appropriately and receive proper payment in a timely manner.

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