An endocrinologist we work with spent 64 minutes with a patient newly on insulin: reviewing two weeks of glucose logs before the visit, examining the patient, teaching the correction scale, adjusting the basal dose, calling the pharmacy about a prior authorization, and writing the note. He billed 99215 and moved on. His biller, who had been to a coding class, added 99417 for the extra time. Medicare denied the add-on. A commercial plan on a similar visit the next week paid it. The physician concluded that prolonged services coding was a lottery and told the biller to stop.
It is not a lottery. It is two different code sets with two different clocks, and the practice was applying the CPT clock to a Medicare claim. Once the thresholds are on a card taped to the monitor, the code is one of the more predictable things in office E/M billing. This article lays out how the codes work, when each one starts, what the note must say and where practices go wrong.
Key takeaways
- Prolonged services add-on codes pay for physician or qualified health professional time beyond a level 5 office visit, and they can be reported only when the visit level was selected on total time, not on medical decision making.
- CPT 99417 starts 15 minutes past the minimum time of 99205 or 99215: at 75 minutes for a new patient and 55 minutes for an established patient, with one unit per full 15 minutes.
- Medicare does not pay 99417. It created HCPCS G2212, which starts 15 minutes past the maximum time of the level 5 code: 89 minutes for 99205 and 69 minutes for 99215.
- Time counts only the billing practitioner's own work on the date of the encounter, face to face and not, and excludes clinical staff time and separately billed services.
- The note needs a total time statement and enough description of the activities to make that time believable. "Total time 62 minutes" alone will not survive a records request.
What prolonged services coding pays for
Since the 2021 office and outpatient E/M changes, a visit level can be chosen either by medical decision making (MDM) or by the total time the physician or qualified health professional (QHP) spent on the date of the encounter. Total time includes preparing to see the patient, reviewing tests and outside records, taking history, examining, counseling and educating, ordering, referring, documenting in the record, and coordinating care, whether or not the patient is in the room. It excludes time on services billed separately, clinical staff time, travel and teaching time.
The highest office visit codes, 99205 for a new patient and 99215 for an established patient, have time floors of 60 and 40 minutes respectively under the current CPT descriptors. A prolonged services code is an add-on for time well past those floors. Because it is built entirely on time, a visit coded to level 5 by MDM cannot carry a prolonged code, no matter how long it took. That rule alone explains a large share of the denials we see.
99417 and G2212: the same idea, different clocks
CPT 99417 is reported for each full 15 minutes of total time beyond the minimum time of the level 5 code. CPT treats 99205's minimum as 60 minutes and 99215's as 40, so the first unit of 99417 is earned at 75 minutes for a new patient and 55 minutes for an established patient. A second unit requires another full 15 minutes: 90 and 70. Partial units are not reported.
Medicare declined to adopt 99417 when it took effect in 2021 because CMS reads the threshold differently. CMS created G2212, "prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure," and counts from the top of the old time range rather than the floor. For 99205 that maximum was 74 minutes, so G2212 starts at 89. For 99215 it was 54, so G2212 starts at 69. The second unit starts at 104 and 84. CMS confirmed those thresholds again in its current Evaluation and Management Services booklet, and they have not changed for 2026. G2212 is valued the same as 99417; the difference is only when it starts.
| Total time reaches | Established patient, CPT payer | Established patient, Medicare | New patient, CPT payer | New patient, Medicare |
|---|---|---|---|---|
| 54 minutes | 99215 | 99215 | 99204 (45 to 59) | 99204 |
| 55 minutes | 99215 + 99417 x1 | 99215 | 99204 | 99204 |
| 60 minutes | 99215 + 99417 x1 | 99215 | 99205 | 99205 |
| 69 minutes | 99215 + 99417 x1 | 99215 + G2212 x1 | 99205 | 99205 |
| 70 minutes | 99215 + 99417 x2 | 99215 + G2212 x1 | 99205 | 99205 |
| 75 minutes | 99215 + 99417 x2 | 99215 + G2212 x1 | 99205 + 99417 x1 | 99205 |
| 84 minutes | 99215 + 99417 x2 | 99215 + G2212 x2 | 99205 + 99417 x1 | 99205 |
| 85 minutes | 99215 + 99417 x3 | 99215 + G2212 x2 | 99205 + 99417 x1 | 99205 |
| 89 minutes | 99215 + 99417 x3 | 99215 + G2212 x2 | 99205 + 99417 x1 | 99205 + G2212 x1 |
| 90 minutes | 99215 + 99417 x3 | 99215 + G2212 x2 | 99205 + 99417 x2 | 99205 + G2212 x1 |
| 104 minutes | 99215 + 99417 x4 | 99215 + G2212 x3 | 99205 + 99417 x2 | 99205 + G2212 x2 |
Read the table for the endocrinologist's 64-minute visit: a CPT-following commercial plan pays 99215 plus one unit of 99417, and Medicare pays 99215 alone. Both results are correct. The biller's error was not adding the code; it was adding the wrong code to the Medicare claim and, at 64 minutes, adding any prolonged code to it at all.
Which payers use which code
Medicare Part B and, in our experience, nearly all Medicare Advantage plans want G2212 and deny 99417 as not covered. Most commercial plans follow CPT and accept 99417 at the CPT thresholds, but a meaningful minority have adopted Medicare's G2212 thresholds in their reimbursement policies while still accepting the 99417 code number, which means a 60-minute 99215 visit gets paid the add-on by one Blue plan and denied by another. State Medicaid programs go both ways. This is why the payer grid we keep for every practice has a column for prolonged services: code accepted, threshold used, and the date the policy was verified.
The related codes for other settings follow the same split. CPT 99418 covers prolonged inpatient, observation and, since 2023, nursing facility and home visits beyond the level 3 codes; Medicare instead uses G0316 for inpatient and observation, G0317 for nursing facility and G0318 for home or residence, each with its own Medicare-specific threshold. And 99415 and 99416, prolonged clinical staff time under physician supervision, are a different service entirely and cannot be reported with 99417 on the same date.
Documentation that supports the time
A time-based level 5 with a prolonged add-on is one of the first things a payer reviewer looks at, and the review is simple: does the note make the time believable? We ask for three things in the note.
- A total time statement for the date of the encounter, in minutes, that says it excludes separately billed services and staff time. For example: "Total time spent by me on the date of this encounter, excluding separately reported services and clinical staff time: 72 minutes."
- A short account of what filled the time. Not a stopwatch log, but enough that 72 minutes is plausible: "Reviewed 14 days of CGM data and the hospital discharge summary before the visit (18 minutes); visit including insulin teaching and correction scale (35 minutes); pharmacy call regarding prior authorization and documentation (19 minutes)."
- Evidence that the time was on the same date. Prep done the night before does not count under the current rules for either code set; if the physician reviews records the evening before, that time belongs to no code.
Two habits get practices in trouble. The first is a template that auto-fills "total time 55 minutes" on every level 5 visit; reviewers spot identical times across dozens of notes immediately. The second is counting the medical assistant's intake, the nurse's injection teaching or the scribe's documentation time. Only the billing practitioner's own time counts, and for split or shared visits, only the time of the practitioner who performed the substantive portion.
Where the denials come from
We see five recurring denial patterns for prolonged services. Billing 99417 to Medicare or a Medicare Advantage plan, denied as non-covered; billing G2212 or 99417 with a level 4 visit or with a level 5 chosen by MDM, denied because the add-on has no qualifying primary service (CO-B15 on many remittances); billing a unit at 60 or 65 minutes to a payer using Medicare thresholds; billing two units where the time supports one; and billing the add-on on a telehealth visit where the payer's telehealth policy excludes it. Every one of these is preventable at charge entry with a threshold card and a payer grid.
When a prolonged code is denied and you believe it was correct, appeal with the note, the payer's own reimbursement policy and a one-line calculation: "Total time 72 minutes; 99215 floor 40 minutes; 99417 threshold 55 minutes; one unit supported." Payers that use the Medicare thresholds will uphold a denial at 60 minutes, and they are right to under their policy; do not spend appeal effort there. Our denial management team sorts prolonged denials into "payer threshold" and "our error" before anything is appealed.
Questions we hear
Can we bill a prolonged code when the level was chosen by MDM?
No. The prolonged codes require the level 5 visit to be selected on time. If a visit clearly meets level 5 MDM and also ran 70 minutes, select the level by time and add the prolonged code; the documentation must then support the time. Choosing MDM for the level and adding time-based prolonged services is the most common self-inflicted denial we see.
Does time spent by the nurse practitioner and the physician add together?
For a split or shared visit in a facility setting, CMS allows the time of both practitioners to be summed when the visit is billed on time, with the substantive portion determining who bills, and Medicare applies its own rules to the prolonged add-on in that situation. In the office, split or shared billing does not apply; one practitioner's time supports the visit. Two practitioners in the same group and specialty seeing the patient the same day are treated as one for E/M purposes, so their time can be combined under CPT rules, but it is worth confirming each payer's policy before relying on that.
Is there a prolonged code for level 4 visits?
Not in the office. A 99214 that runs long is a 99215 if the time reaches 40 minutes; below that it stays a 99214. The prolonged add-ons attach only to the level 5 codes. In the inpatient and other settings covered by 99418 and G0316 to G0318, the same principle applies to the highest level code in each family.
What to do this week
- Print a threshold card: 99417 at 55 and 75 minutes; G2212 at 69 and 89 minutes; one unit per full 15 minutes after that. Tape it where charges are entered.
- Run a report of 99417 and G2212 claims for the last 12 months by payer with the paid or denied result, and match the denials to the five patterns above.
- Check the ten largest payers' reimbursement policies for prolonged services and record the code and threshold each one uses on the payer grid.
- Fix the total time statement in the level 5 templates so it is a required free-text field, not a default number.
- Review ten recent time-based 99215 notes for a plausible account of the time, and share the findings with the physicians; our RCM training sessions include this exercise.
