Prolonged outpatient E/M service, each 15 minutes (first 15-29 min beyond threshold)
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Prolonged service time not documented or doesn't meet 15-minute threshold
Very Common99417 (prolonged E&M add-on) requires 15+ minutes BEYOND the time range for base E&M code. For 99215 (40-54 min), must document 55+ minutes total (40 + 15 threshold). For 99205 (60-74 min), must document 75+ minutes (60 + 15 threshold). Each 99417 unit = additional 15 minutes. Audits target practices billing 99417 without explicit time documentation or rounding up from 12-13 minutes.
Common Causes
- • Total time 52 minutes with 99215 - only 12 minutes over base, need 15 minimum
- • Time documented in ranges ('45-60 minutes') not specific enough
- • No explicit total time statement - arrival/departure times unclear
Resolution Strategy
Add explicit total time documentation: 'Total face-to-face and non-face-to-face time on date of encounter: 68 minutes.' Specify activities: patient interview (25 min), exam (15 min), reviewing labs (8 min), care coordination (10 min), counseling (10 min). Must exceed base code time by 15+ minutes (e.g., 99215 base = 40-54 min, so need 55+ min total for first 99417 unit). Appeal with enhanced time documentation. Success rate 50-70% if legitimate prolonged service.
2. Billed with codes not eligible for prolonged service add-on
Common99417 can ONLY be billed with office/outpatient E&M codes 99205, 99215, G0402, G0438, G0439. Cannot bill with 99211-99214, 99202-99204, hospital codes, or procedures. Automatic denial if billed with ineligible base code.
Common Causes
- • Billed 99417 with 99214 - not eligible (use 99215 if time qualifies)
- • Billed with 99204 instead of eligible 99205
- • Combined with procedure code requiring separate global period time
Resolution Strategy
Verify base code is eligible (99205, 99215, G0402, G0438, G0439). If base code wrong, rebill with correct base code + 99417. If base code is 99214 but 55+ minutes documented, change to 99215 + 99417. Cannot appeal if billed with ineligible code - must rebill correctly.
Relative Value Units (RVUs)
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Clinical Information
When to Use
Additional time beyond threshold for office E/M codes 99205, 99215 requiring prolonged service
Common Scenarios
Documentation Requirements
- Total time spent on date of encounter documented
- Base E/M code time threshold documented
- Specific activities during prolonged time described
- Medical necessity for additional time explained
Coding Guidelines
Common Modifiers
Bundling Rules
- Must be billed with 99205 or 99215 only
- Cannot be billed alone; requires base E/M code
- Each unit represents 15 minutes beyond threshold
- First 15-29 minutes of prolonged service = 1 unit
Exclusions
- 99354-99355 (prolonged service without direct patient contact)
- Cannot be used with 99201-99204, 99211-99214
- Cannot be used with time-based codes like 99483
Coding Notes
Clinical scenarios
- Total time spent on date of encounter documented
- Base E/M code time threshold documented
- Specific activities during prolonged time described
- Total time spent on date of encounter documented
- Base E/M code time threshold documented
- Specific activities during prolonged time described
- Total time spent on date of encounter documented
- Base E/M code time threshold documented
- Specific activities during prolonged time described
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Frequently Asked Questions
CPT 99417 is the billing code for "Prolonged outpatient E/M service, each 15 minutes (first 15-29 min beyond threshold)". Additional time beyond threshold for office E/M codes 99205, 99215 requiring prolonged service
Medicare pays approximately $29.76 for CPT 99417 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.
CPT 99417 has a total RVU of 0.97, broken down as: Work RVU 0.61, Practice Expense RVU 0.32, and Malpractice RVU 0.04. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 99417 is "Prolonged service time not documented or doesn't meet 15-minute threshold". 99417 (prolonged E&M add-on) requires 15+ minutes BEYOND the time range for base E&M code. For 99215 (40-54 min), must document 55+ minutes total (40 + 15 threshold). For 99205 (60-74 min), must document 75+ minutes (60 + 15 threshold). Each 99417 unit = additional 15 minutes. Audits target practices billing 99417 without explicit time documentation or rounding up from 12-13 minutes. Common causes include: Total time 52 minutes with 99215 - only 12 minutes over base, need 15 minimum; Time documented in ranges ('45-60 minutes') not specific enough. Appeal success rate is approximately 40-60%.
Key documentation requirements for CPT 99417 include: Total time spent on date of encounter documented; Base E/M code time threshold documented; Specific activities during prolonged time described; Medical necessity for additional time explained. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 99417: Must be billed with 99205 or 99215 only. Cannot be billed alone; requires base E/M code Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 99417 include: None typically required (Add-on code automatically bundled with base E/M). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.
The typical time requirement for CPT 99417 is 15 minutes of additional time beyond total time threshold for base E/M code. Time-based codes require documentation of the actual time spent providing the service.