2025 CPT code 99416
(Active) Effective Date: N/A Evaluation and Management - Prolonged Services Feed
Prolonged clinical staff service during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; each additional 30 minutes (List separately in addition to code for prolonged service)
Applicable modifiers may include those relevant to the primary E/M service.
Medical necessity for prolonged clinical staff services should be clearly documented and justified based on the individual patient's condition and the complexity of the services provided. The additional time spent by the clinical staff must be beyond the usual time allotted for the primary E/M service and must be medically necessary to address the patient's needs.
In addition to the highest time in a range included in the descriptor for a primary evaluation and management (E/M) service, the clinical staff spends additional time on that office or outpatient service under the provider’s direction. The service requires direct contact with a patient.
In simple words: The clinical staff spends additional time directly with the patient on an office or outpatient evaluation and management service. This code is used for each additional 30 minutes of that extra time spent by the staff, under the provider's supervision.
Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician or other qualified health care professional supervision; each additional 30 minutes (List separately in addition to code for prolonged service)
Example 1: A patient with complex medical history requires extended discussion and education about their condition and treatment plan, exceeding the typical time allotted for the E/M service.The clinical staff, under physician supervision, provides an additional 45 minutes of face-to-face time with the patient, addressing their questions and concerns.99415 would be reported for the first hour, and 99416 would be reported once for the additional 30 minutes (even if discontinuous)., A pediatric patient with autism requires extra time and support from clinical staff during their office visit. The staff spends an additional hour and 40 minutes with the patient and family to complete the visit, which was longer than the typical time frame. 99415 would be reported for the first hour, and 99416 would be reported once for the additional 30 minutes., An elderly patient with cognitive impairment requires prolonged assistance from clinical staff during a post-operative follow-up visit. The staff spends 1 hour and 15 minutes providing additional care beyond the time included in the E/M service.99415 would be billed for the first hour, and 99416 would *not* be billed, as the additional time is only 15 minutes.
Documentation should support the medical necessity of the prolonged clinical staff time, the total face-to-face time spent by clinical staff with the patient and/or family, and the direct supervision by the physician or other qualified healthcare professional.The primary E/M service should also be documented appropriately.
** Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.Facilities may not report 99415, 99416.
- Global Days: Not applicable
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Many specialties may use this code when prolonged clinical staff time is medically necessary. Some examples are: Family Medicine, Internal Medicine, Pediatrics, Geriatrics.
- Place of Service:Office, On Campus-Outpatient Hospital, Off Campus-Outpatient Hospital