Prolonged E/M (99417 vs. G2212) & Critical Care (99291/99292) Calculator
Spot the exact 14-minute outpatient prolonged gap (and 75–103 minute critical care gap) where commercial payers pay an add-on code and Medicare denies the claim.
| Base | AMA 99417/99292 starts | CMS G2212/99292 starts | Medicare denies the add-on between |
|---|---|---|---|
| 99205 | 75 min | 89 min | 75–88 min |
| 99215 | 55 min | 69 min | 55–68 min |
| 99291/99292 | 75 min | 104 min | 75–103 min |
2026 AMA CPT 99417 vs. CMS Medicare G2212 Threshold Matrix
Commercial payers following AMA CPT start counting prolonged 15-minute units from the minimum time of the base E/M code, whereas CMS Medicare counts from the maximum time plus a full 15 minutes (MLN006764, May 2026):
| Primary Code | Base Time Range | AMA 99417 ×1 Starts | CMS G2212 ×1 Starts | Danger Window |
|---|---|---|---|---|
| 99205 (New Patient) | 60–74 min | 75 min | 89 min | 75–88 min (CMS pays 99205 only) |
| 99215 (Established) | 40–54 min | 55 min | 69 min | 55–68 min (CMS pays 99215 only) |
| 99483 (Cognitive) | 60–85 min | 75 min | 100 min | 75–99 min |
| 99291 / 99292 (Critical Care) | 30–74 min | 75 min (+99292 ×1) | 104 min (+99292 ×1) | 75–103 min (CMS denies 99292) |
KX modifier threshold: have you crossed $2,480 this year?
For CY 2026 the KX threshold is $2,480 for PT and SLP combined and $2,480 separately for OT (CMS Therapy Services CY 2026 update; re-confirmed at each November re-check). Crossing it is not a cap and not permission: append KX only on claims where continued therapy is medically necessary and the record documents it. The year-to-date fields in the allocator above run this check on every calculation.
Frequently Asked Billing Questions
Why did Medicare deny CPT 99417 on an 80-minute 99205 visit?
Medicare never accepts 99417 and requires HCPCS G2212, which only begins after 15 full minutes beyond the 74-minute maximum of 99205 (89 minutes total).
How many minutes are needed to bill 99292 under Medicare in 2026?
Per CMS Booklet MLN006764 (May 2026), a full 30 minutes beyond the initial 74-minute 99291 period—104 cumulative minutes—is required to bill 99292 × 1.
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