I have a provider who is assessing a patient during stimulation testing and wants to bill 99358/99359. After reading guidelines I have the understanding for prolonged services is not used for assessing the patient while under treatment for a certain time and also CPT 99358/99359 is for NON face to face. Can someone help validate this for me please or I would happily love some great resources.
This is the documentation the provider wants to use to validate CPT 99358/99359
0830: Patient called in from the lobby. Ambulated without any difficulty withmom. Vital Sign taken and within normal limits. No s/s of pain and discomfort.
0845: Patient ambulated to room and placed to gurney without any difficulty. IV Saline Lock started to (22) Anticubital w/ 22g and first baseline blood draw was collected without any difficulty. IVSL is flushed with Normal Saline and there is no s/s of infiltration noted.
900
r. xxx in room assessing patient.
09:12: .25 mg cortrosyn given to patient IV push by Sarah as ordered by MD
0950r. xxx in room assessing patient.
1012: +60 min blood draw was collected without any difficulty. IVSL is flushed with Normal Saline and there is no s/s of infiltration noted.
IV D/C per protocol. Pt was given juice and crackers, was able ambulate with no problems
1015: Dr. xxx in room assessing patient, discharge instructions given to parents
This is the documentation the provider wants to use to validate CPT 99358/99359
0830: Patient called in from the lobby. Ambulated without any difficulty withmom. Vital Sign taken and within normal limits. No s/s of pain and discomfort.
0845: Patient ambulated to room and placed to gurney without any difficulty. IV Saline Lock started to (22) Anticubital w/ 22g and first baseline blood draw was collected without any difficulty. IVSL is flushed with Normal Saline and there is no s/s of infiltration noted.
900
r. xxx in room assessing patient.09:12: .25 mg cortrosyn given to patient IV push by Sarah as ordered by MD
0950
r. xxx in room assessing patient.1012: +60 min blood draw was collected without any difficulty. IVSL is flushed with Normal Saline and there is no s/s of infiltration noted.
IV D/C per protocol. Pt was given juice and crackers, was able ambulate with no problems
1015: Dr. xxx in room assessing patient, discharge instructions given to parents