Your providers will find it easier to hit the required time for a prolonged inpatient or observation visit thanks to a correction to the final 2023 Medicare physician fee schedule. The update, announced today, cuts 15 minutes from the threshold times for G0316 (Prolonged inpatient or observation services by physician or other QHP).
CMS published a chart with the reduced times for inpatient and observation hospital codes
99223, 99233 and
99236 in
CMS 100-04, Change Request 13064. Bobbi Buell, principal with onPoint Oncology in San Francisco, alerted
Part B News to the discrepancy between the change request and the
physician fee schedule.
It appeared that the change request contained a few typos. In the final rule CMS gave an extensive explanation for the time thresholds which matched the rule’s prolonged time chart.
“CMS is aware of this issue and is working to address it,” a CMS spokesperson said in response to a question from
Part B News on March 10. CMS then
published a correction to the final rule the includes the new time thresholds on March 14. The effective date for the corrections is Jan. 1. That means the change request is accurate, and the fee schedule revisions should be considered final.
The changes were prompted by “technical errors in the calculations of the time thresholds,” according to the correction.
The following chart provides the corrected and original threshold times.
|
Primary E/M Service
|
Prolonged Code
|
Corrected threshold times (minutes)
|
Original threshold times (minutes)
|
|
Initial hospital visit (99223)
|
G0316
|
90
|
105
|
|
Subsequent hospital visit (99233)
|
G0316
|
65
|
80
|
|
Same-day admit/discharge (99236)
|
G0316
|
110
|
125
|
The update should also make it easier to calculate visit times for initial and subsequent hospital visits. The new times for the visits match the threshold times for code 99418, the new prolonged service code for E/M visits in a facility setting.
The correction also revises the times for G0316 throughout the final rule.
For example, this revised paragraph (emphasis added): “Thus, a practitioner could bill G0316 for base code CPT code 99223 when 90 minutes is furnished for an initial visit on the date of encounter. For the purposes of applying the proposed prolonged code, the CPT code 99223 total time is rounded to 75 minutes on the date of encounter. A single prolonged service period would end after 90 minutes, 15 minutes beyond 75 minutes. A practitioner would bill HCPCS code G0316 once the 15-minute increment for G0316 is completed, when 90 minutes has been furnished.”
Replaces the paragraph that was published in the final rule (emphasis added): “Thus, a practitioner could bill G0316 for base code CPT code 99223 when 105 minutes is reached for an initial visit on the date of encounter. For the purposes of applying the proposed prolonged code, the CPT code 99223 total time is rounded to 75 minutes on the date of encounter. The prolonged service period would begin at 90 minutes, 15 minutes beyond 75 minutes. A practitioner would bill HCPCS code G0316 once the 15-minute increment for G0316 is completed, at minute 105.”
CMS did not change the threshold times for prolonged services in the nursing facility (G0317) or home/residence settings (G0318). If your private payers have adopted Medicare’s prolonged service codes, make sure they’re aware of this update.