The Centers for Medicare & Medicaid Services (CMS) issued a notice March 14 correcting several errors in the 2023 Medicare Physician Fee Schedule (MPFS) final rule. Most notably, CMS is correcting technical errors in the calculations of the time thresholds for reporting evaluation and management (E/M) prolonged inpatient/observation services HCPCS Level II code G0316.
Errors Found in MPFS Final Rule
CMS published the calendar year 2023 payment policies under the MPFS to Part B and coverage policies on Nov. 18, 2022. Since then, the healthcare industry has been scratching their heads, wondering how CMS did the math when calculating the time thresholds for G0316.
The descriptor for the code in question is as follows:
G0316 Prolonged hospital inpatient or observation care evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using 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 (List separately in addition to CPT codes 99223, 99233, and 99236 for hospital inpatient or observation care evaluation and management services). (Do not report G0316 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99418, 99415, 99416). (Do not report G0316 for any time unit less than 15 minutes)
What is Being Corrected:
The time threshold determines when a practitioner can bill G0316 for prolonged services when billing CPT codes 99223, 99233, and 99236 based on time.
Per the amended final rule, a practitioner can bill G0316 with initial inpatient/observation visit CPT® code 99223 “when 90 minutes is furnished for an initial visit on the date of encounter. … the CPT code 99223 total time is rounded to 75 minutes on the date of encounter. … A practitioner would bill HCPCS code G0316 once the 15-minute increment for G0316 is completed, when 90 minutes has been furnished.”
Thus, the time threshold for reporting G0316 with 99223 is 90 minutes, not 105 minutes as originally stated.
Also, per the amended final rule, a practitioner can bill G0316 with subsequent inpatient/observation visit CPT® code 99233 “when 65 minutes is reached for a subsequent visit on the date of encounter. … the CPT code 99233 total time is rounded to 50 minutes on the date of encounter. A single prolonged service period would end after 65 minutes, 15 minutes beyond 50 minutes.”
Thus, a practitioner can bill G0316 once the 15-minute increment is completed after 65 minutes of a 99233 has been furnished, not 80 minutes as originally stated.
Finally, per the amended final rule, a practitioner can bill G0316 with inpatient /observation same-day admission/discharge CPT® code 99236 “at 110 minutes for same-day discharge. … the CPT code 99236 total time is rounded to 95 minutes completed within 3 calendar days of the encounter. A single prolonged service period would end after 110 minutes, 15 minutes beyond 95 minutes.”
Thus, a practitioner can bill G0316 once the 15-minuted increment is completed after 110 minutes of a 99236 has been furnished (not 125 minutes, as originally stated).
The corrections are retroactively effective Jan. 1, 2023.
For more information, visit: https://www.aapc.com/blog/87562-cms-corrects-time-thresholds-for-prolonged-services/