CPT 99354 is an add-on code for prolonged face-to-face visits in the office or outpatient setting. It covers the first hour of extra time beyond the usual service. For example, if a psychiatrist’s typical office visit (E/M) would end at 30 minutes, 99354 applies when the provider spends 30 minutes or more beyond that time with the patient. (AMA CPT defines 99354 as “prolonged E/M or psychotherapy service(s) … first hour (list separately in addition to code for office or other outpatient E/M or psychotherapy)”.) 1 In practice, 99354 is used when a mental health provider (usually a psychiatrist or psychiatric NPP) conducts an unusually long visit requiring at least 30–60 extra minutes of direct patient contact.
99354 is always billed with an eligible primary service (see below) on the same date by the same clinician. 2 It can never be billed alone.
This code requires direct face-to-face patient contact. Time spent charting or indirect work does not count (CMS specifically excludes non–face-to-face time).
CPT’s official description implies it can accompany either an E/M visit or a psychotherapy visit, but in practice it is intended as an add-on to Evaluation & Management (E/M) office codes (99201–99215) or equivalent (e.g. domiciliary/home visit codes). 2 1
Use 99354 when a behavioral health appointment goes well beyond its normal length. For example, a psychiatrist’s med-management visit or psychotherapy-oriented appointment that extends 60+ minutes past the usual time may justify reporting 99354. It cannot be used for crisis therapy (see “90840” below) or to split a single session into multiple codes. Proper documentation of total face-to-face time and medical necessity is required.
Only certain providers can report 99354, and only in the correct setting:
Clinicians: Physicians (MD/DO) and qualified nonphysician practitioners (NPs, PAs, clinical nurse specialists, etc.) who are eligible to bill Medicare E/M codes. 2 In behavioral health, this typically means psychiatrists or behavioral health NPPs. Psychologists, social workers or counselors generally do not bill E/M codes, so they typically cannot use 99354 on their own (they use psychotherapy CPT codes instead).
Companion Codes: The primary visit must be an office/outpatient E/M or similar code (e.g. 99213–99215 for established patients) or equivalent domiciliary/home visit codes. 2 (CMS also listed outpatient consultation and home service codes as companions.) The add-on 99354 is reported in addition to that base code for the first extra hour of service. 1
Setting: Office, clinic, outpatient hospital or health center, nursing home/domiciliary, or home visits qualify – any setting where an outpatient E/M code applies. 2 The physician must see the patient face-to-face in person (or via interactive telehealth, see below).
Telehealth: During the COVID-19 PHE, Medicare and many payers allowed 99354 via telehealth when appended with modifier 95/GT on a qualifying E/M visit. 1 (Appendix P lists 99354 as an approved telehealth code.) Post-PHE rules vary by payer; check current telehealth policies. In any case, the full face-to-face time requirement still applies even if via video.
CPT 99354 is time-based. You must exceed the usual service time by a substantial margin and document it precisely:
Threshold Time: The total face-to-face time on that date (including the time for the underlying E/M) must meet or exceed a threshold. CMS uses typical time + 30 minutes as the threshold. For example, if the underlying E/M code’s typical time is 20 minutes, then 99354 is billable at 50 minutes total (20+30). (Once 99354 is used, each additional 30-minute block beyond that is reported with add-on code 99355.) In contrast, the CPT narrative says “one hour beyond”, but most payers (including Medicare) require only 30 min beyond the threshold. 2 3
Minimum Time: By convention, 99354 is not reported unless you have a full 30+ minutes beyond the companion code’s typical time. If you spend less than 30 extra minutes, you generally do not report 99354. (Likewise, 99355 each require at least 15 minutes.) 4
Documentation: Record the start and end times (or cumulative face-to-face blocks) in the medical record. 3 Note that time may be non-continuous; you can count separate segments of direct care across the visit. The chart must also describe the medically necessary content of the extra time spent (e.g. complex counseling, extensive coordination, urgent management tasks, etc.). Maintain clear notes justifying why the prolonged time was needed.
Content: While CPT 99354 may be used when providing “counseling and coordination of care,” some payers (including Medicare) require the highest level E/M code if most of the visit is counseling. 3 In other words, if over 50% of the visit is counseling, a psychiatrist would typically use the top-level established visit (99215) as the companion code along with 99354, rather than a lower E/M code.
When billing CPT 99354, follow these rules:
Always with E/M: List 99354 on the same claim as the eligible E/M (or domiciliary/home visit) code that represents that visit. Do not bill 99354 by itself or on a separate date. 2
Add-On: Do not use modifier 25 for 99354 – it is inherently an “add-on” service. It is reported on a new line as an add-on to the primary E/M code line. Only one unit of 99354 may be reported per day (covering the first extra hour). Use 99355 for further time.
Telehealth: If the base E/M is telehealth-eligible and you have the required extra time, append 99354 with modifier 95 (or other payer-specified modifier) on the claim. Check if the insurer still allows prolonged codes via telehealth.
ICD-10: Use diagnosis codes that reflect the reason for the visit (e.g. depression, anxiety, etc.). There is no special ICD code for prolonged services – the same mental health diagnoses apply as for the E/M visit.
Continuity: If 99354 is reported, ensure all services that day by that physician relate to the same episode of care. You cannot string unrelated visits to accumulate time.
Medicare: Note that traditional Medicare no longer pays CPT 99354 for office/outpatient E/M. In 2023 CMS deleted 99354–99357 (prolonged services). 5 Instead, Medicare’s approach is:
For outpatient visits, Medicare now uses HCPCS code G2212 as an add-on for each 15 minutes beyond the level-5 threshold on the same date. (Per CMS guidance, you must not bill G2212 on the same date as 99354cms.gov, effectively replacing 99354/99355.)
The AMA’s replacement CPT code for prolonged office visits is 99417 (15-min increments after 75 minutes), but Medicare does not recognize 99417 on its claims. 5 (Medicare Advantage plans may or may not accept 99417, so verify.)
Commercial Payers: Private insurers generally follow CPT guidelines unless otherwise specified. Many still allow 99354 (with 99355) as defined in the CPT codebook. Some may have adopted AMA’s newer prolonged codes (99417) or require G2212-like logic. Each payer’s policy may differ:
Time requirements: Insurers often mirror Medicare’s practical thresholds (30-min beyond typical, 15-min units) even if CPT text says 60/30. Always confirm whether your plan expects 99354 only after a full hour beyond or if 30 minutes suffices. 2
Payments: Reimbursement rates for 99354 are typically add-on to the primary E/M payment. Check your fee schedules – some plans bundle prolonged time, while others pay an incremental fee. For example, an insurer might pay full 99354 once and diminishing amounts for each 99355.
Documentation audits: Commercial payers may audit prolonged codes closely because of the potential for abuse. Be prepared to show exact times and justify “why so long.” (Medicolegal reviewers expect the same documentation rigor as Medicare.)
In all cases, confirm parity: some plans waive cost-sharing for tele-behavioral health (e.g. during COVID) or have special rules on extended sessions.
Do keep precise time records. Note start/end times and cumulative face-to-face minutes to support each 99354/99355 billed. 3
Do pair 99354 only with the correct companion code(s) on the claim (e.g. 99215 or appropriate domiciliary code). The presence of 99354 without a covered E/M will trigger denial. 2
Do use the highest-level E/M code appropriate (99214/99215) when counseling predominates. Don’t under-code just to make threshold easier.
Do apply modifiers as required (95/GT for telehealth, etc.). Check if a payer requires a specific modifier or excludes 99354 from telehealth coverage.
Don’t bill 99354 for psychotherapy-only visits (CPT 90832/90834/90837) – those codes have no prolonged add-on (except crisis codes below). 99354 is not intended as an extension of a standard therapy code unless your payer explicitly says otherwise.
Don’t submit 99354 if the extra time is non–face-to-face (waiting for labs, family discussion without patient, administrative tasks, etc.). Only direct patient contact time counts.
Don’t report 99354 unless you have met or exceeded the required extra time. Reporting it prematurely (e.g. only 10 extra minutes) is contrary to CPT/CMS policy. 2
Don’t bill 99354 on the same date as certain other time-based services (e.g. prolonged inpatient codes, care management codes) unless allowed. For Medicare, 99354 cannot be used with G2212 on the same day. 6
Don’t forget consent. Extended sessions may have consent/billing implications (especially for self-pay or out-of-network); be sure patients know if they will incur additional charges for prolonged time.
CPT 90837 and 90840 are psychotherapy codes, not E/M. Understanding when to use each:
90837 (Psychotherapy, 60 min): Use 90837 (no add-on) for a non-crisis therapy session of roughly 53–60 minutes when a licensed therapist (psychologist, social worker, counselor or psychiatrist) is providing psychotherapy (talk therapy). This covers one hour of therapy time. No prolonged add-on code exists for standard psychotherapy beyond 60 min; if the session unexpectedly runs longer, some therapists have no official code and must either end at 60 or break into two sessions. CPT does not allow adding 99354 to 90837 – that would violate the rule of needing an E/M primary. Instead, the clinician must either accept an underpayment or, if applicable, code it as an E/M encounter (see below).
90839/90840 (Crisis Psychotherapy): If the visit is a crisis session (patient in acute distress requiring urgent intervention), use 90839 for the first 60 minutes. If it extends beyond 60 minutes, use add-on 90840 for each additional 30 minutes. Do not use 99354 for crisis work; 90840 is the correct add-on in crisis situations. 1 (For example, an agitated patient requiring 90 minutes of intervention would be 90839 + 90840.)
99214/99215 + 99354: A psychiatrist or NP who codes an encounter as a medical E/M (e.g. evaluating a complex patient with medication changes) may use 99354 if it’s extremely long. For instance, a 90-minute session focusing on both psychotherapy and medication management might be coded as 99215 + 99354 (and 99355 if beyond 120 min). Use this when the visit includes significant medical decision-making or coordination (as opposed to being purely psychotherapy).
Rule of thumb: For a routine non-crisis therapy visit up to 60 minutes, use 90837 (or 90847 if including family). If the session is a crisis >60 min, use 90839/90840. If the session is a very long evaluation/management session by a physician/NPP (e.g. complex med-psych visit) beyond typical time, use an E/M code plus 99354.
Prolonged service codes help align reimbursement with the care provided. For busy psychiatrists, 99354 (and 99355) allow additional payment when spending an hour or more beyond a standard visit. This can make it financially viable to offer extended appointments for patients in crisis or with complex needs. For patients, it means one longer visit can be covered rather than rushing or splitting care into multiple visits. In behavioral health, longer sessions may improve outcomes for severe cases.
Clinicians: Appropriately billing 99354 ensures the extra work (and overhead) of long sessions is compensated. This can improve practice sustainability and provider morale when intensive visits are often needed.
Patients: Knowing that extended therapy or med-management visits are recognized can improve access to necessary care. Rather than end a helpful session prematurely at 60 minutes, clinicians and patients can continue working together when needed.
In all cases, use 99354 judiciously. Document thoroughly and bill it only when truly justified by the care delivered. 3 2 Proper use avoids audit risk and ensures patients and payers see the value of that extra clinical time.
Sources:
American Medical Association - Telehealth Services Covered by Medicare and Included in CPT Code Set https://www.ama-assn.org/system/files/telehealth-services-covered-by-medicare-and-included-in-cpt-code-set.pdf
Centers for Medicare & Medicaid Services (CMS) - CMS Manual System (R1490CP) https://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r1490cp.pdf
University of New Mexico Hospitals - Prolonged Services Documentation https://hospitals.health.unm.edu/intranet7/apps/doc_management/index.cfm?document_id=763485
American Medical Association - Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99417) Code and Guideline Changes https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
National Government Services (NGS Medicare) - Evaluation and Management https://www.ngsmedicare.com/web/ngs/evaluation-and-management?selectedArticleId=894584
CMS - CMS Manual System (R10505CP) https://www.cms.gov/files/document/r10505cp.pdf
