CMS Now Covers 99358, +99359 Prolonged Services

CMS Now Covers 99358, +99359 Prolonged Services

The Centers for Medicare & Medicaid Services (CMS) typically does not allow separate payment for physician services that do not require face-to-face time with a patient. As of Jan. 1, 2017, CMS has made an exception and will now allow Medicare coverage for non face-to-face prolonged service codes 99358 Prolonged evaluation and management service before and/or after direct patient care; first hour and +99359 …each additional 30 minutes (List separately in addition to code for prolonged service), in compliance with CPT® guidelines.
Source: CMS Transmittal 3678, Change Request 9905 (Dec. 16, 2016)
CPT® Evaluation and Management/Prolonged Services instructions dictate:

Codes 99358 and 99359 are used when a prolonged service is provided that is neither face-to-face time in the office or outpatient setting, nor additional unit/floor time in the hospital or nursing facility setting during the same session of an evaluation and management service and is beyond the usual physician or other qualified health care professional service time.

Report Prolonged Services with E/M Codes

Codes 99358 and 99359 are to be reported in addition to other E/M service codes, to which they relate. “For example,” CPT® explains, “extensive record review may relate to a previous evaluation and management service performed earlier and commences upon receipt of past records.”
In keeping with CPT® requirements, CMS stresses, “codes 99358 and 99359 cannot be reported during the same service period as complex chronic care management (CCM) services or transitional care management services. They are not reported for time spent in non-face-to-face care described by more specific codes having no upper time limit in the CPT code set.” CMS further stipulates, “99358 and 99359 can only be used to report extended qualifying time of the billing physician or other practitioner (not clinical staff).”
Codes 99358 and 99359 are time-based and include “the total duration of non-face-to-face time spent by a physician or other qualified health care profession on a given date providing prolonged services, even if the time… is not continuous,” according to CPT®. The codes are applied as follows:
Total duration of services      Coding
< 30 minutes                                    Not reported separately
30-74 minutes                                  99358
75-104 minutes                                 99358, 99359
105-134 minutes                               99358, 99359 x 2
Documentation should summarize the necessity and specific content of the prolonged services. See the CPT® codebook for additional guidelines to report prolonged services.

John Verhovshek
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About Has 569 Posts

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

19 Responses to “CMS Now Covers 99358, +99359 Prolonged Services”

  1. Kristina Bennett says:

    Do the Prolonged Service codes require the documentation of “start and stop” times or can the documentation of the overall number of minutes suffice?

  2. Vel says:

    I know the time doesn’t have to be continuous, however does it have to be done all in one day or can it be accumulative throughout several days?

  3. Ruth Muench says:

    I’ve missed the Coding knowledge that John V highlights. Welcome back! These codes will be helpful for home bound situations, especially when information wasn’t shared at an office visit. lso can be helpful for people with driving restrictions due to eyesight problems. It can take all day when scheduling free transportation for a 25-30 min office visit. Family member told me about this. Blind in one eye and used cane to walk. She got a tour of the whole city while various stops were made to pick up and drop off others for patient office visits. Thanks to John for Highlighting these codes and Congrats to CMS for their insight.

  4. Essie says:

    Does any one know how documentation must be done by the provider. For example if the Dr. spent 30 minutes later that day speaking to other Doctors regarding the patients condition after the patient was checked out for referring purposes. How will he document that in the progress notes?

  5. Christinne Harris says:

    My providers would like to know if these codes are supposed to be billed on the same date that they are done OR bill out on the day of the e&m visit? My thoughts would be that they bill on the day the prolonged work was done, but I have search and cannot find the answer. They are concerned about whether they are supposed to open another encounter from the associated visit. Please let me know if you can.

  6. Renee says:

    Did you get a response?

  7. munendra kumar says:

    As above mentioned that 99358 and 99359 are reprorted in addition to other E/M services but 99358 is not an add on code, so why it will code in addition to other E/M services. 99358 can bill separately.

  8. Miriah says:

    Do we know if there is a maximum amount of time that can be billed per day? Also, for NY does anyone know the RVU for 99358 and 99359?

  9. December Daugherty says:

    If you can’t attach this to a CCM code what can you use it with. Most conditions are chronic. It needs to be tied to an ICD 10 code. Had an issue when started using it recently due to a need for a qualifying service/procedure.

  10. Amy young says:

    Can one provider bill the 99358 code and another provider in the same office do the following e/m visit? Also, can since the prolonged service non- face to face visit code (358) is a before or after prolonged services, what happens if you bill it and then the patient gets sent out without you doing the follow up E/M visit? Do you have to cancel the charge for the non face to face?

  11. Caroline Wolbrecht says:

    I have a similar question to Amy Young.
    Scenario: Cardiology Imaging Specialist is asked to review medical records, EKGs, TEEs, and other diagnostics to see if they are fit for a procedure. The physician performing the extensive record review may NEVER actually see the patient face-to-face, but one of the group’s cardiologists may. When this record review occurs BEFORE there is ever a face-to-face encounter, should the physician hold their billing until there is a confirmed face-to-face? Can the related “primary” E/M service be from someone else in the group, but not the same sub-specialty as the physician performing the extensive record review? I have read at least 20 articles on this, including the CMS Medicare Processing Manual, CH 12, MLN Matters Articles, FP, MedScape, AMA Errata and I cannot specifically find anything in writing for this. Any help or direction on this would be greatly appreciated.

  12. Arce Villalobos says:

    My providers would like to know if they can only bill the 99358 without any other procedures. Any help is greatly deeply appreciated. Thank you!

  13. Richard P Paczynski, MD says:

    John, thank you for the update.
    Do you know of any distinctions for the 99358 and 99359 billing when it comes to Outpatient, Hospital Inpatient Services, LTACHs and SNFs ?
    This is especially important for SNFs because many SNFs are now steeped in post-acute care patients fresh out of hospitals or LTACHs. Many times I’ve provided initial and subsequent E/M services for patients who have outside-facility chart reviews, physician-to-physician communication needs, and/or family contact needs that are extensive. In fact, sometimes at or exceeding the E/Ms I would do for an acute care or LTAH patient.
    Bottom line question: Can I use 99358 and 99359s for extended services that are necessary to proper completion of a preceding 99306 or 99310, but extending well beyond the time used in doing the face-to-face encounter ?
    Any feedback in this regard much appreciated.
    RP Paczynski MD

  14. Sarah C says:

    Did anyone ever find out if these codes require start and stop times? Thanks!

  15. Phillip Bowden says:

    Can these codes be used prior to seeing a new patient, for instance a patient with extensive oncology history is coming in for evaluation. Review of CT/ PET/ Pathology/ etc, etc, …

  16. Edwin S Jacob CCS says:

    Does anyone know if the Providers Documentation needs to state the length of time spent on this prolonged service please?

  17. Casie Connors, CPC, CCC says:

    I am not sure if anyone answered your question yet but that is precisely what the codes can be used for.
    I have another question: I was discussing this with my cardiologists last night and the question was posed as to whether this could be billed (or if they would be penalized) if a patient no shows for the related visit?
    Ex: 45 minutes of extensive record and imaging review is performed prior to a new patient consult the next day. Dr. bills 99358 for their time but the next day the patient no shows for the consult.

  18. Alex A. says:

    I was looking for answers as well and found this published on a AAP website. I found it helpful even though I am not in peds.
    There are two types of outpatient-based prolonged services:
    Direct (face-to-face) +99354 and +99355
    Non-direct (non-face-to-face) 99358 and +99359
    For prolonged direct services:
    A minimum of 30 minutes above the time listed in the primary code is required (see table for time increments).
    Designated add-on codes can be reported only with the following primary service codes: 90837, 90847, 99201-99215, 99241-99245, 99324-99337, 99341-99350, 99483.
    All designated primary codes are time-based.
    Time spent by physician or OQHCP does not have to be continuous.
    Only face-to-face time with patient and/or family (including guardians) is counted.
    If reporting the primary service code based on time in lieu of key components, the time criteria in the highest code in the code set (e.g., 99215) must be met before prolonged service time can begin.
    Code 99355 must be reported with 99354.
    For prolonged non-direct services:
    At least 30 minutes must be spent on a single calendar date (see table for time increments).
    Prolonged services include time spent performing non-direct services such as chart reviews.
    Prolonged services must relate to an upcoming encounter or a recent one.
    Codes may be reported alone (99358) or in conjunction with another service.
    Code 99359 must be reported with 99358.

  19. Ronald Devine says:

    Old string, but still looking for answers. Can 99358/ 99359 be used on different days and relate to the same E/M visit? For instance, patient seen face-to-face on Monday with E/M visit and then on Tuesday reviewed records, etc for non-face-to-face of 35 minutes (99358) and then on Thursday did more non-face-to-face work of 40 minutes (99358). Can you bill 99358 x2 along with the E/M visit on that Monday? Are the 99358/ 99359 codes billed on dates work was done or on date to which the related E/M visit was performed?