In the 2017 Medicare physician fee schedule, the CMS officially activated CPT codes 99358 and 99359 as reimbursable codes for non-face-to-face prolonged services performed in the office or outpatient setting, hospital or nursing facility by physicians or other qualified health practitioners (not clinical staff).
The CPT codes are defined as
- 99358: Prolonged evaluation and management service before and/or after direct patient care; first hour; and
- 99359: Prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes (list separately in addition to code for prolonged service).
The two codes are intended to reimburse providers for work conducted outside of an office visit if the non-face-to-face service goes beyond the usual time a provider would spend on a service. Although practices may find additional opportunities with these codes to get paid for background work or extensive chart reviews performed, practices are cautioned to keep an eye on billing requirements, because payers and contractors have varying guidelines.
CPT codes 99358 and 99359 have strictly defined time components, meaning the provider must meet over half of the specified time before reporting these codes. CPT code 99358 is for the first hour of non-face-to-face services, and may be billed before or after direct patient care; CPT code 99359 is an add-on code, billable only in conjunction with 99358. In the case of these codes, a provider must spend at least 31 minutes or more before billing code 99358, and 76 minutes or more before adding code 99359.
The adopted CPT guidelines for reporting codes 99358 and 99359 consist of the following points:
- This service may be provided on the same day or on a day different from the face-to-face service.
- It is for extensive time in addition to seeing the patient and must relate to a service for a patient in which direct face-to-face patient care has occurred, or will occur, and be part of ongoing patient management.
- Code 99358 is not an add-on code. That is, it can be reported on the day when no other service is provided.
- Code 99359 is an add-on code to code 99358.
- Non-face-to-face prolonged service may not be reported for review of the provider’s own records.
- The time during the day of a non-face-to-face service does not need to be continuous.
- The CPT instructions include the restrictions that you are not to report these services during the same month as complex chronic care management (99487, 99489) or transitional care management (99495, 99496).
- You cannot double count the time for these non-face-to-face prolonged services codes or time spent in certain other activities represented by specific CPT codes. The manual lists CPT codes that Medicare bundles or doesn’t cover; these codes can be reported when related to a non-face-to-face service code that has a maximum published time (e.g., telephone service).
Although the CPT descriptor includes extensive record review as the only example, other coordination services may meet the requirements, such as creating future or ongoing patient management plans. The ACR recommends documenting time in the medical record and describing the work that was done.