With the extensive changes in office and outpatient services (99202-99215), many aspects still need to be addressed in medical billing services. One of the important aspects is related to prolonged services without face-to-face contact. Effective capture of extended, non-face-to-face patient care services beyond the limitations of a typical Evaluation and Management (E/M) encounter is crucial for accurate outpatient billing.
This article gives you answers to all unanswered questions regarding the appropriate use of codes 99358/ 99359 and how you can incorporate them into your billing appropriately. Another thing we are going to cover is how they should be recorded with office or outpatient E/M services represented by codes (99202-99215).
Applications of 99358/99359
CPT code 99358 refers to Prolonged E/M service encounters before and/or after direct patient contacts consisting of the initial hour. Add-on code 99359 refers to the service that is provided for any additional time as follows – every 30 minutes, or every fraction thereof, beyond the initial time that has been billed.
These codes permit physicians and non-physician practitioners to bill for additional time spent on activities that are not face-to-face encounters but that may require a great deal of work for care outside of a traditional office visit setting.
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Criteria for Usage
To qualify for billing under 99358 and 99359, the following criteria must be met:
Time Requirements: A minimum of 31 minutes must be spent on non-face-to-face services to bill for 99358.
-For 99359, an additional 30 minutes is required beyond the initial hour.
Related to an E/M Service: The service must be related to an E/M service that has occurred or will occur, involving ongoing patient management.
Services Included
Examples of activities covered by 99358 and 99359 include:
- Extensive review of patient records.
- Coordination with other healthcare providers.
- Analysis of diagnostic results.
- Developing treatment plans based on detailed patient history.
Factors to Consider During Coding
- E/M Visit Concurrency: Following the 2021 CMS Final Rule, billing 99358/99359 on the same date of service as established patient visit codes (99202-99215) is no longer permissible. Consider alternative prolonged service codes (e.g., 99417) in such scenarios. Payer verification is always recommended.
- Pre- and Post-Visit Activities: These codes are not intended for routine pre-visit and post-visit tasks like cursory record review or documentation that typically occur within a standard visit timeframe.
CPT Codebook Guidelines
According to the official CPT codebook rules, reporting these protracted codes may be eligible for an extensive record review relating to an E/M service that has occurred or will occur. It says this:
- The reporting of this service should be done in connection with other medical services provided by physicians or other qualified professionals, including management and evaluation services at any level. The date of this extended service may differ from the date of the linked primary service. A comprehensive record review, for instance, can be connected to an earlier assessment and management service. Ongoing patient management and service or patient where (face-to-face) patient care has occurred or will occur are required.
- When a doctor or other qualified health care professional provides prolonged service on a particular date, even if their time is not continuous, they can report the total amount of non-face-to-face time they spent working on the project using the codes 99358 and 99359.
As previously mentioned, 99358 is classified as a prolonged service code, meaning that it corresponds to an E/M service provided before too, on the same day as (except from 99202–99215), or following direct patient care. 99358 may be reported on its own since it is NOT an add-on code, but the description needs to make it clear that it is connected to an E/M encounter.
A doctor or other qualified healthcare professional (QHP) must conduct code 99358, which can be reported in addition to any level of E/M treatment in the outpatient, inpatient, or observation setting (e.g., 99231, 99213, 99244), except for 99211.
RUC’s Role in Valuation
In particular, some of the auditors have noted concern over the valuation of work components for the various medical services that have been classified by the CPT/RUC Workgroup. To develop a coding framework for those office visits, reducing administrative burden while developing an appropriate payment valuation, the AMA CPT Editorial Panel and the AMA/Specialty Society Relative Value Update Committee RUC formed this workgroup. In a 2019 statement, the workgroup highlighted several key points regarding time-based coding:
- Time-Based Reporting: It also made a point that if codes are reported based on time, then the specific time contingency contained in the code descriptor has to be complied with. For instance, the code 99204 for alphanumeric identifies that at least 45 to 59 minutes of the physician or QHP’s time is spent on such visits on the day for service for face-to-face and non-face-to-face related activities.
- Inclusive Time Calculation: The quantitative representation of the work value for each code is obtained by the time the physician pays attention to the patient from three days before the visit through the day of the visit and up to seven days after the visit.
- Survey Insights: Survey respondents indicated that the time required to perform services was generally 23%-38% longer than what is reflected in the Medicare Physician Payment Schedule, suggesting that the services are undervalued by 13%-34%.
Time Allocation for Pre-Service and Post-Service Activities
To better understand the time allocation for pre-service and post-service activities, the 2021 Medicare Physician Fee Schedule Proposed Rule included the following recommendations:
| Code | Pre-service Time | Intra-Service Time | Post-Service Time | Actual Total Time | RUC-recommended Total Time |
| 99202 | 2 minutes | 15 minutes | 3 minutes | 20 minutes | 22 minutes |
| 99203 | 5 minutes | 25 minutes | 5 minutes | 35 minutes | 40 minutes |
| 99204 | 10 minutes | 40 minutes | 10 minutes | 60 minutes | 60 minutes |
| 99205 | 14 minutes | 59 minutes | 15 minutes | 88 minutes | 85 minutes |
| 99211 | 5 minutes | 2 minutes | 7 minutes | 7 minutes | |
| 99212 | 2 minutes | 11 minutes | 3 minutes | 16 minutes | 18 minutes |
| 99214 | 7 minutes | 30 minutes | 10 minutes | 47 minutes | 49 minutes |
| 99215 | 10 minutes | 45 minutes | 15 minutes | 70 minutes | 70 minutes |
This table illustrates the time considered part of pre-service and post-service activities. Time spent beyond these allocations can justify the use of prolonged service codes when applicable.
Understanding these nuances helps healthcare providers better document and bill for the comprehensive care they provide, ensuring appropriate reimbursement for the extensive non-face-to-face services that are crucial to patient management.
Summary
Essentially, the matter revolves around what the payer regards as included in the E/M service and whether they follow the stated inclusion periods of the RUC workgroup, which are 3 days before and 7 days following the service, during which specific E/M-related services (such as calling with test results, ordering medications, ordering new tests, consulting with another provider, and reviewing medical records) are carried out.
According to CPT codebook guidelines, codes 99358/99359 may be reported based on all the information provided unless a payer specifies otherwise, provided the following conditions are met:
- The time criteria were fulfilled, resulting in a minimum of thirty minutes of non-face-to-face services (such as a thorough examination and summary of records).
- The service is associated with another E/M visit that has occurred or is scheduled to occur.
- As may be seen in the above table for an O/O E/M, time also surpasses the RUC time requirements.
As always, the time spent providing non-face-to-face services must be supported by the documentation.
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