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Prolonged service, visit complexity code update, E/M guideline update
December 23, 2020

This article is for all professional and outpatient facility providers

Prolonged service and visit complexity codes

For 2021, the American Medical Association and the Centers for Medicare & Medicaid Services have released new CPT and HCPCS codes for prolonged evaluation and management (E/M) and visit complexity inherent to E/M.

Beginning January 1, 2021, we will reimburse for visit complexity inherent to the E/M service (HCPCS G2211) for Medicare Advantage products only.

Code Narrative
G2211 Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition)

Consistent with our existing payment policy, we will not reimburse the new prolonged E/M service codes 99417 and G2212 that are effective January 1, 2021.

Code Narrative
99417 Prolonged office or other outpatient evaluation and management service beyond the minimum required time of the primary procedure which has been selected using total time
G2212 Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact

E/M guideline reminder

We notified you on September 1 that Blue Cross would adopt the 2021 American Medical Association new guidelines for outpatient evaluation and management code selection. As a reminder, professional RVU and fee updates will follow our normal update schedule:

  • Commercial professional fee update will be September 1, 2021
  • Medicare Advantage professional fee update will be January 1, 2021

To access this News Alert, log in and go to News. Look for the September 1 News Alert called "2021 evaluation and management guidelines update."

Resources

  • For detailed information about these changes, please refer to the AMA website.
  • We will update our Evaluation and Management Services payment policy with this information. To download this payment policy, log in and click Find a Payment Policy on the right side of your home page. Or, go to Office Resources>Policies & Guidelines>Payment Policies.

Questions?

If you have any questions, call Network Management and Credentialing Services at 1-800-316-BLUE (2583). As always, thank you for the care you provide to our members.

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