CMS FY 2023 Final Rule Changes – Prolonged Services

Author:  Caroline Wolbrecht, CPC, CPC-I, OHCC

Revised:  April 19, 2023

Physician with Arms Crossed

CMS (Centers for Medicare and Medicaid Services) has released their CY2023 Final Rule. For now, the main focus of this article is the new Prolonged Service G-codes that will be used in lieu of the AMA’s 2023 CPT codes, effective January 1, 2023.

These codes will be replacing existing codes that describe prolonged services, specifically inpatient prolonged services CPT codes 99356 (Prolonged service in the inpatient or observation setting), and 99357 (Prolonged service in the inpatient or observation setting).

Prolonged Service Medicare G-Codes:

  • 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, 993X0
    • Do not report G0316 for any time unit less than 15 minutes   
    • This was listed as (GXXX1) in the proposed rule
    • G0316 was added to the Medicare Telehealth Services List on a Category 1 basis
    • This is the CMS equivalent to the AMA’s CPT Code 99418
  • G0317 – Prolonged nursing facility 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 99306, 99310 for nursing facility evaluation and management services
    • Do not report G0317 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 993X0
    • Do not report G0317 for any time unit less than 15 minutes
    • This was listed as (GXXX2) in the proposed rule
    • G0317 was added to the Medicare Telehealth Services List on a Category 1 basis
  • G0318 – Prolonged home or residence 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 99345, 99350 for home or residence evaluation and management services
    • Do not report G0318 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99417
    • Do not report G0318 for any time unit less than 15 minutes to describe prolonged services associated with certain types of E/M services
    • G0318 was listed as GXXX3 in the proposed rule
    • G0318 was added to the Medicare Telehealth Services List on a Category 1 basis

Note that CMS also created “time-range thresholds” in their final rule (page 590):

UPDATE:  3/14/2023 CMS “corrected” threshold times to align with CPT, retroactive to January 1st.CMS corrected time

For CMS prolonged service time examples, see Sample Q/A sway. CDI has also published a tip sheet on their UTP Connect Page.

Shared Visit – Substantive Portion (1 year delay):

Also in the Final Rule, CMS has decided to delay the implementation of  the “more than half of the time spent” as the substantive portion in a shared facility setting visit. For 2023, CMS will continue to allow the demonstration of the substantive portion in one of two ways:

  1. Documentation of 1 of 3 key components (History, Exam, or MDM) in its entirety, or
  2. Documentation of more than half of the total time spent on the date of the encounter

Want to learn more?

If you would like to learn more, or need specialty specific training, please reach out to Caroline.Wolbrecht@uth.tmc.edu.