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Wiki Billing e/m visit and 99358

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shanamarie

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Hello-

I'm looking for some clarification on billing an office visit and the prolonged service without direct patient contact 99358. Sometimes when a patient comes in with a very complex case the provider has to do an extensive review of medical records, so they would like to bill 99358. My question is when billing the 99358 does the original office visit need to be billed on time as well? Or are we able to bill that visit based on history, exam and MDM components?

Any clarification would be greatly appreciated. Thanks!
 
The E&M code can still be based on History, Exam, and MDM. When allowing for the time component of 99358 make sure that this time and service is not factored into your E&M level. The documentation for your code 99358 needs to be clear in the time aspect and information reviewed.

Example:
Began review of extensive medical records for John Doe at 11:30am. Reviewed patients long term stay at ABD Medical Center due to COPD and Uncontrolled DM. Also called and spoke to Dr. Johnson who was the hospitalist who treated the patient while inpatient. Review and consultation with hospitalist ended at 12:25pm.
 
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