General Surgery Coding Alert

See a boost for complex or chronic cases.

Do your general surgeons sometimes do extensive work evaluating a patient case “behind the scenes” without a mechanism to capture fees for those services? 

Good news: As of Jan. 1, you now have a way to account for that work and collect appropriate reimbursement. CMS paved the way in transmittal # R3678CP, which states, “In CY 2017, CPT® codes 99358 and +99359 (prolonged services without face-to-face contact) are separately payable under the Medicare Physician Fee Schedule [MPFS], reflecting policies finalized in the CY 2017 MPFS Final Rule.”

Do this: Learn how to use 99358 and +99359 to report extended, non-face-to-face qualifying time of the billing physician or other practitioner (not clinical staff) beyond the normal time for a billable E/M service.

Discover New Life for Old Codes

The relevant codes have been around for a while, as follows:

• 99358 — Prolonged evaluation and management service before and/or after direct patient care; first hour
• +99359 — … each additional 30 minutes (List separately in addition to code for prolonged service)

Change: Previously, CMS bundled 99358 and +99359 with the related face-to-face E/M service code, meaning that, effectively, you could not bill Medicare for 99358 and +99359. The 2017 MPFS final rule changes that by allowing separate payment for 99358 and +99359 in addition to an E/M code.

According to the MPFS Final Rule, allowing separate payment for 99358 and +99359 will “provide a means to recognize the additional resource costs of physicians and other billing practitioners when they spend an extraordinary amount of time outside of an E/M visit performing work that is related to that visit and does not involve direct patient contact (such as extensive medical record review, review of diagnostic test results, or other ongoing care management work).”

“This could be huge for physicians that handle surgery for chronic problems like transplants, because those patients often have extensive records that require review,” says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash. “Additionally it could be helpful for surgeons who work as part of collaborative treatment teams who meet to discuss complex cases, like oncology,” she adds.

Watch Documentation and Details

Using 99358 or +99359 for prolonged, non-face-to-face services has some restrictions. For instance, you should turn to other codes if the prolonged service is for face-to-face time in the office or outpatient setting, or additional unit/floor time in the hospital or nursing facility setting during the same session of the E/M service.

To use codes 99358/+99359, the prolonged service must relate to the E/M service for a patient where direct face-to-face care has already occurred or will occur, and also relate to ongoing patient management.

Interpretation: If your surgeon performs an E/M service, but spends additional non-face-to-face time evaluating the case, you can appropriately bill an E/M code plus 99358/+99359 as documented in the surgical note. CMS also makes clear that the prolonged, non-face-to-face services needn’t take place the same day as the accompanying E/M service. “Our final policy will adopt the CPT^® guidance that allows the prolonged time to be reported for time on a different day than the companion E/M code,” the agency says in the final rule.

Caveat: Don’t use 99358/+99359 for an initial or subsequent E/M visit that qualifies for Chronic Care Management (CCM) services. For those cases, you should turn instead to codes such as 99490 (Chronic care management services…)

Nor should you use the other prolonged service codes +99354-+99357 (Prolonged … service …) for non-face-to-face services. “Codes +99354-+99355 (Prolonged evaluation and management or psychotherapy service[s] [beyond the typical service time of the primary procedure] in the office or other outpatient setting requiring direct patient contact beyond the usual service …) are used only in the outpatient setting, but apply to a regular E/M service when a patient presents with a problem or when the prolonged service is required during a psychotherapy session,” says Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, N.M. “These codes require direct face-to-face interaction with the patient.”

On the other hand, with +99356-+99357 (Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service…), the prolonged service time is based on unit/floor time devoted to the care of the inpatient. “Codes +99356-+99357 only apply to situations where the patient has been admitted to the hospital, or has been admitted to observation status,” says Witt.

Understand The Importance of Time

To report a prolonged service code, your documentation must support the medical necessity for services that extend beyond the usual E/M service time.

Limits: For non-face-to-face prolonged services, you need to document at least 30 to 60 minutes of time spent by your surgeon to report 99358, even if it’s on a different date or at a different Place of Service (POS) than the E/M visit. If the time exceeds 60 minutes by at least 15 minutes, you can report 99358 and a unit of+99359.

After the initial hour, you may keep adding units of +99359 for each additional 30 minutes of service on the same date. You may add one more unit of +99359 for the final 15 to 30 minutes the surgeon spends on the task.

Caution: “Coders have to be careful of ‘double dipping’ and reporting the same amount of time under two codes,” says Laureen Jandroep, CPC, COC, CPC-I, CPPM, founder/CEO Certification Coaching Organization, LLC in Oceanville, N.J. “Prolonged services are for time reported beyond the time spent on any other service reimbursable under the Medicare Fee Schedule,” she cautions.