Prolonged Service Codes

With all the mental health I am doing, I have multiple occasions a week to bill the prolonged service code after a 99215. We are not getting paid for this. Here is a message from my billing manager…
“UHC & Aetna have denied the code 99417. They state it is a missing/invalid code. I have called & spoke with the insurances first. They sent the claim back for review. Got second denial-called again-spoke to 3 different people in 3 different departments on 1 child (Ihave reference numbers for each call & the name of whom I spoke with), then I faxed in their reconsideration form along with the medical records & new code guidelines & rules. Those are pending yet.”

We have posted this on SOAPM as well, and thank you Richard Lander for the reminder about the Hassle Factor Form via AAP, and to the other practice in Virginia that chimed in. Is everyone having similar issues? Is anyone getting these paid? This is valid code for well spent time with severe mental health patients that require every minute I bill for. Why are the insurance companies balking at this?

Because it’s not a “procedure”. Extract some cerumen and you’ll double your collection. Sad.

We have only billed on patient with this code. Their insurance was Aetna and it paid fine. We had a similar issue with the 99072 and one of our local payers and I was told that if it is a valid code they have to process the claim, but they don’t have to pay for it. Our visit that paid was billed with 1 unit 99215 and 1 unit 99417 and no modifiers.


It sounds like you may enjoy the counseling aspect of the services that you render. If that is true, the insurance companies may not value that aspect of your services. That leaves you with two obvious options, 1-discontinue providing such long services, and but your patient and their family know why, 2-continue providing those patients those prolonged services And do not expect payment for them -( but continue to bill for them).

There are certainly other options out there, I’m curious to hear how successful docs have been to get some of these codes paid for when insurance company has said they don’t pay for that code.

good morning
I recently had an afternoon with 4 consecutive BH patients , each took an hour (including calls , counseling etc) I will not know for a few weeks what the reimbursement is on my 99215 codes,. Happy to follow up once I know. Unfortunately there is an increase in BH needs by our patients and they do not have many other options than their pediatricians.

We billed Maryland Medicaid and denied CPT 99417 (no modifier) as invalid code. CPT 99215 (modifier 25) paid. Sent “appeal”/“inquiry” with records 2 weeks ago and no adjudication to date. Patient dx: Status Asthmaticus, Hypoxemia Respiratory Distress despite 3 albuterol, 2 atrovent, 40 mg Solumedrol and 5 L FM oxygen. Called for Ambulance for transport to local ED. I guess next time just divert to ED.

We’ve had it paid by 1199 , UHC Community and BCBS Healthplus. But not straight Medicaid. Jury is still out on some of our other private payors.

I’m still having this issue as well. Especially with the “preventive care” visit that turns into extended counseling about return to school/COVID concerns, discussion about COVID vaccine for kids, stress & anxiety/depression, overweight, etc. I spent 75 min with a patient yesterday who came in for “preventive care” (OCD, body image, asthma & allergies, travel consultation also)!" I will get paid LESS if I bill 99394-25 + 99215 than I will if I ONLY bill 99215, and give up the appropriate 99417. Is anyone getting anywhere with 99417?