Blog Details

A claim comes back denied, and the line item reads 99354. The biller checks the modifier, checks the diagnosis pointer, checks the payer portal for a coverage note. Nothing looks wrong on the surface. The problem is the code itself it hasn't existed since January 1, 2023, and no amount of clean documentation will make a deleted CPT code pay.

This happens more than practices like to admit. Old EHR templates still have 99354 baked into a superbill macro from 2019. A biller who trained years ago still reaches for it out of habit. A locum psychiatrist brings coding habits from a previous job where the switch never got made. Whatever the cause, the fix isn't a corrected claim with the same code it's understanding what actually replaced prolonged services, and why the replacement looks different depending on whether the visit was an E/M service or a psychotherapy session.

This guide walks through what CPT 99354 was, why it's gone, what current coding pathways apply in its place, and where behavioral health billing runs into a wrinkle that general medical billing guides tend to skip entirely.

What Is CPT 99354?

CPT 99354 was an add-on code for prolonged services with direct patient contact, reported alongside a qualifying primary evaluation and management (E/M) visit when a physician or other qualified healthcare professional spent significantly more face-to-face time with a patient than the primary code's typical time allowed. It covered roughly the first hour beyond that typical time, with its companion code, 99355, picking up each additional 30-minute block.

The code wasn't exclusive to physical medicine. In 2016, the AMA extended prolonged services to non-physician behavioral health providers, and it became reportable with CPT 90837 (individual psychotherapy, 60-minute session) once a session ran 90 minutes or longer. A year later, that same logic extended to CPT 90847 (family or conjoint psychotherapy) for sessions of 80 minutes or more. For a stretch of years, this was the standard way a therapy practice captured extra reimbursement for an unusually long session.

None of that applies anymore. Understanding what 99354 used to do matters mainly so a practice can recognize it in old documentation, old payer contracts, and old training materials and stop treating it as a live option.

Is CPT 99354 Still Active?

No. CPT 99354 was deleted from the CPT code set effective January 1, 2023, along with its direct companions 99355, 99356, and 99357. Any claim submitted today with 99354 on it will process as an invalid or deleted procedure code, regardless of payer, regardless of how well-documented the visit was.

It's worth separating this from two other prolonged-service codes that sometimes get lumped in by mistake: 99358 and 99359. Those cover non-face-to-face prolonged evaluation and management time on a date separate from the actual visit reviewing records the night before, for instance. They technically still exist in the CPT book, but Medicare has assigned them an invalid status and doesn't reimburse them, with no direct Medicare replacement offered. Commercial payer treatment of 99358/99359 varies, so this is one of the places where "check the payer" isn't a throwaway line it's the actual answer.

Why CPT 99354 Was Deleted

The deletion wasn't a standalone event it was the second phase of a multi-year rewrite of how E/M visit levels get selected. CMS moved first, creating HCPCS code G2212 back in 2021 and telling Medicare Administrative Contractors to stop recognizing 99354 for office and outpatient visits. The AMA followed in the 2023 CPT restructuring, folding the entire prolonged-services family for direct-contact E/M visits into two streamlined replacements 99417 for office/outpatient and 99418 for everything else and deleting the old tiered "first hour, then 30-minute chunks" structure entirely.

The underlying logic was to align prolonged services with the same time-based E/M selection model CMS had already introduced for office visits. Once a visit level could be chosen purely on total time rather than a mix of history, exam, and medical decision-making, a single per-15-minute add-on made more sense than a two-tiered code pair built around 30-minute increments. It's a cleaner system on paper. In practice, it meant thousands of superbills, EHR templates, and internal coding guides needed to be rebuilt and a lot of them weren't.

How Prolonged Services Used to Work

Under the old rules, 99354 couldn't stand alone. It attached only to a qualifying primary E/M code, and only after the visit had already run at least 30 minutes past that code's typical time the clock didn't start at minute one of overtime. Documentation had to show total time, or a start and stop time, along with a clinical reason the extended time was necessary. 99355 then picked up each additional 30-minute block after that.

For behavioral health specifically, the psychotherapy application worked the same way structurally but had its own thresholds: 90 minutes total for 90837, 80 minutes total for 90847. A therapist running a 100-minute trauma-processing session could, at one point, legitimately bill 90837 plus one unit of 99354. That pathway is gone, and nothing sits in its place which is the single most important thing to understand before moving on to what current billing actually looks like.

Current Alternatives to CPT 99354

This is where guidance falls apart on a lot of competitor content, because the honest answer isn't one code it depends on whether the primary service was an E/M visit or a psychotherapy session, and on which payer is on the other end of the claim.

Office and Outpatient E/M Visits

Medicare uses G2212. It attaches only to a small set of primary codes selected using time most commonly the highest-level established or new patient office visit, or the cognitive assessment and care planning code and only once the primary code's own time threshold has already been met. Most commercial payers instead recognize CPT 99417, structured the same way but billed as a standard CPT code rather than a HCPCS G-code. If your practice bills a mix of Medicare and commercial patients, that split alone is worth building into your coding workflow as a standing rule rather than a case-by-case judgment call.

Inpatient, Observation, Nursing Facility, and Home or Residence E/M

Medicare splits this into three separate HCPCS codes depending on setting G0316 for inpatient or observation care, G0317 for nursing facility visits, and G0318 for home or residence visits. Commercial payers generally consolidate all three into a single CPT code, 99418. A psychiatric consult-liaison service or an inpatient psychiatric billing workflow that regularly runs long visits needs to track which of these applies before the claim goes out, since submitting the wrong one is functionally the same error as submitting a deleted code.

Psychotherapy: 90837 and 90847 Have No Current Replacement

This is the part that catches behavioral health practices off guard, and it's not a gap in this guide it's a gap in the code set itself. 99417, G2212, 99418, and the Medicare G-codes are all defined as E/M add-ons. None of them can be reported alongside a standalone psychotherapy code. A 90-minute individual session and a 55-minute individual session both bill as one unit of 90837, at the same rate, with no mechanism to separately capture the extra time.

For a therapy and counseling billing practice that built scheduling or fee expectations around the old add-on, that's a real revenue conversation, not just a coding footnote. It also means clinical notes documenting "session extended due to crisis" no longer translate into extra reimbursement the way they used to the medical necessity might be real, but the billing pathway to monetize it isn't there anymore.

Which Payers Handle Prolonged Services Differently

Medicare's approach is the most rigid of the group: it only recognizes its own HCPCS G-codes for prolonged services, it only allows them with a short list of primary codes selected by time, and it does not extend any prolonged-service pathway to psychotherapy. Commercial payers have more flexibility in principle, since they aren't bound by CMS's fee schedule structure, but that flexibility cuts both ways some have adopted 99417/99418 cleanly, some require prior authorization before an extended visit will pay at all, and some behavioral health carve-out plans have policies that predate the 2023 changes and haven't been fully updated.

None of that is a reason to fall back on a deleted code just because a payer's system hasn't caught up. If a legacy claims edit somewhere in a payer's system happens to let 99354 through, that's a processing gap, not a valid billing pathway and it's the kind of thing that surfaces badly in a post-payment audit. The safer approach is confirming current policy directly, which is exactly the kind of payer-specific verification that eligibility verification should be catching before the appointment ever happens, not after the claim denies.

Medicare Billing Considerations

Two rules trip up practices more than any others. First, the primary visit has to be selected using time, not medical decision-making if the level was chosen based on complexity rather than minutes spent, no prolonged-service code attaches, full stop. Second, G2212 only pairs with a specific, narrow set of primary codes; it doesn't ride along with every office visit level, only the ones already representing the top time tier.

Because CMS updates these thresholds and code pairings as part of its annual Physician Fee Schedule rulemaking, exact minute counts are worth confirming against the current-year CMS guidance rather than assumed from a prior year's chart. A threshold that was accurate in 2023 rulemaking may have shifted since. This is one of the areas where a certified coding team earns its keep not by memorizing a number once, but by rechecking it every January.

Commercial Insurance Considerations

Commercial payer policy on prolonged services is genuinely inconsistent, and any guide that tells you otherwise is oversimplifying. Some plans mirror Medicare's structure closely. Others have their own internal time thresholds, require documentation beyond what CPT itself demands, or carve prolonged services out of certain behavioral health contracts entirely. A handful still require prior authorization for extended visits above a certain frequency, treating repeated prolonged claims from the same provider as a utilization flag.

The practical takeaway: verify the specific payer's current policy before assuming 99417 or 99418 will pay the way G2212 does for Medicare. Building that check into claim submission rather than discovering the policy gap from a denial three weeks later is the difference between a clean first-pass claim and a rework cycle.

Documentation Requirements

Prolonged-service documentation hasn't gotten lighter since 2023 if anything, tying everything to time makes the record more exposed to scrutiny, not less. At minimum, the note needs to establish total time or start/stop times, confirm that the primary E/M level was selected using time, and describe what happened during the additional time in enough detail to support medical necessity.

Medical Necessity

A long visit isn't automatically a billable long visit. Payers expect the extra time to be clinically justified a psychiatric crisis that escalated mid-appointment, a complex medication history that required extended review, family involvement that genuinely extended the encounter, or the use of an interpreter. What doesn't hold up under review is a pattern of routinely running every visit long as a matter of scheduling preference and billing the add-on as a default. Medical necessity documentation should read like a clinical explanation, not a time log with no context attached.

Common Billing Mistakes

The most frequent errors aren't complicated they're leftover habits:

• Still submitting 99354, 99355, 99356, or 99357 because an EHR charge template was never updated after 2023
• Attaching a prolonged E/M add-on to a psychotherapy code like 90837 or 90847, which no payer will pay under current CPT rules
• Selecting the primary E/M level by medical decision-making, then trying to add a time-based prolonged code onto it
• Assuming any level-4 or level-3 visit qualifies for a prolonged add-on when only specific top-tier, time-selected codes do the same confusion that shows up when practices mix up 99213 versus 99214 selection criteria more broadly
• Missing total time documentation entirely, relying on a vague note like "session ran long"

Common Denials

Modifier Usage

Prolonged-service add-on codes generally don't require a modifier of their own the qualifying primary code and the documented time do the work. Where modifiers matter is at the intersection with other same-day services. If a psychiatric E/M visit and a psychotherapy add-on (90833, 90836, or 90838) are billed together on the same date, that combination has its own coding logic separate from prolonged services entirely. And if any portion of the extended visit was delivered by telehealth, place-of-service coding and modifier selection 95 versus GT, POS 02 versus 10 follow their own payer-specific rules that are worth reviewing on their own; our modifier 95 telehealth guide breaks that down separately. National Correct Coding Initiative edits can also bundle certain same-day combinations, which is a scrubbing issue rather than a documentation issue.

Examples of Correct Coding

Real Practice Scenarios

A 12-provider outpatient group brought on a new EHR in 2022 and imported its old superbill templates wholesale. Nobody rebuilt the prolonged-services line item, so every provider who documented an extended visit kept generating 99354 claims well into 2024 all of them denying, all of them requiring manual correction. The fix wasn't complicated once someone noticed it: pull the deleted codes from the template, replace them with the correct crosswalk by payer, and the denial pattern stopped within one billing cycle.

A different practice ran into the opposite problem. Clinicians were documenting "extended session" language in notes for long 90837 sessions, expecting the biller to append a prolonged-services code the way they always had. The biller, working from current CPT guidance, correctly declined to add a code that no longer exists but nobody had told the clinical team that the option was gone. That's a communication gap as much as a coding one, and it's exactly the kind of disconnect that regular coding and documentation training is meant to close.

Coding Tips for Better Reimbursement

• Audit EHR charge templates and superbills specifically for 99354, 99355, 99356, and 99357 don't assume a past cleanup caught every instance
• Confirm, payer by payer, whether G-codes or CPT 99417/99418 apply before the claim goes out
• Train clinical staff on time-based documentation standards, since the coding decision depends entirely on what the note supports
• Build payer verification into intake through eligibility verification so prior-authorization requirements for extended visits surface before the appointment, not after the denial
• Track annual CPT and CMS updates every January, since thresholds and code pairings can shift year to year

Compliance Checklist

• No claims submitted with 99354, 99355, 99356, or 99357 for current dates of service
• Prolonged add-ons attached only to time-selected primary E/M codes on the eligible list
• No prolonged-service codes attached to psychotherapy codes under any payer
• Documentation includes total time or start/stop times and a medical necessity narrative
• Payer-specific policy confirmed before billing 99417, 99418, or the Medicare G-codes
• EHR templates and charge masters reviewed at least annually against the current CPT/HCPCS set

How Professional Billing Support Helps

A lot of this comes down to maintenance more than expertise someone has to actually go back into the EHR every year and check whether last year's charge master still matches this year's code set. That's easy to deprioritize inside a clinical practice where the immediate pressure is patient care, not claims edits. An outside medical coding team built specifically around behavioral health tends to catch legacy codes like 99354 before they ever leave the building, because checking for exactly this kind of drift is part of the job rather than an occasional side project.

The same applies downstream. When a prolonged-services claim does deny whether for a documentation gap or a payer policy quirk denial management that categorizes the root cause and feeds it back into the scrub rules stops the same mistake from repeating next month. And for practices weighing whether to handle this internally at all, a full revenue cycle partner that already understands the psychiatry, psychology, and outpatient behavioral health billing landscape can shortcut a lot of the trial-and-error a practice would otherwise absorb on its own.

Future Billing Updates for 2026

CPT and CMS both release updates on an annual cycle, effective each January 1, and prolonged services has been a moving target for several years running first the 2021 Medicare shift to G2212, then the full 2023 restructuring. There's no indication of another overhaul specific to prolonged services on the immediate horizon, but the pattern of the last five years is a reasonable argument for treating this guide as a snapshot of the current code set rather than a permanent reference. Recheck CMS's annual Physician Fee Schedule materials and the current CPT codebook each year rather than assuming this year's rules carry forward unchanged.

Key Takeaways

• CPT 99354, along with 99355, 99356, and 99357, has been deleted since January 1, 2023, and cannot be billed for current dates of service
• Medicare uses HCPCS G2212 (office/outpatient) and G0316/G0317/G0318 (other E/M settings) in its place
• Most commercial payers use CPT 99417 (office/outpatient) and 99418 (other E/M settings) instead
• There is currently no prolonged-service replacement for psychotherapy codes 90837 or 90847 extended sessions bill at the standard rate regardless of length
• Documentation must tie directly to time-based E/M selection and medical necessity, not just a long appointment
• Payer policy on prolonged services varies enough that blanket assumptions aren't safe verify before billing

Conclusion

CPT 99354 is a closed chapter, not an open question the code is gone, and no version of "but the documentation was solid" brings it back. What matters now is knowing which of its several replacements applies to a given visit, recognizing that psychotherapy sessions were left without any replacement at all, and making sure that reality has actually made it into the EHR templates your billers use every day. Practices that get tripped up by this usually aren't confused about billing principles in the abstract they're just working from a system that never got updated. If a coding review of your own charge master and denial history sounds worth doing, a free A/R audit is a reasonable place to start.

Frequently Asked Questions