Prior to 2017, prolonged service without patient contact CPT codes 99358 & 99359 were not separately payable, and were included for payment under the related face to-face Evaluation and Management (E/M) service code. Beginning in 2017, CPT codes 99358 and 99359 are separately payable under the Medicare Physician Fee Schedule

CPT Codes:

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

 Guidelines:

** The service provided on the same day or on a different day than the face-to-face service,but not related to face to face time during E/M service

** It is for “Extensive Time/ beyond the usual time” spend by the physician for extensive record review or other activities related tO patient ongoing management like peer to peer discussion and discussion with family.

** It must relate to the past or future direct, face-to-face care of the patient and be a part of ongoing patient management.

** If an additional service is rendered on the same date of service, it may be reported inaddition to the prolonged service codes

** The time does not need to be continuous.

** CPT 99358 can be reported separately and reported only once per day.

** CPT 99358 is used to report the first hour of prolonged service on the given date regardless of POS

** Code 99359 is an add-on code for CPT 99358 it is used for each additional 30 minutes

** Prolonged service less than 30 minutes should not be reported separately

Time Calculation:


Total Duration of Prolonged Service CPT Codes

Less than 30 minutes Do not Bill
30-74 minutes (30 minutes -1 hr. 14 min) 99358*1
75-104 minutes (1 hr. 15 min -1hr. 44 min) 99358*1& 99359*1
105 or more ( 1 hr. 45 min or more ) 99358*1 & 99359*2or more each additional 30 minutes

DWC COVERAGE

** DWC will cover this service effective from 03/01/2017

** RFA (Request for authorization) not require for this service

** DWC adopted AMA guidelines for CPT 99358 & 99359

** Effective for all dates of service on or after April 1st, providers will be reimbursed for a maximum of one unit of 99358 and two units of 99359 of non-face-to-face time per patient on any given day. Hence, provider will only be reimbursed for 2 hours and 14 minutes for one patient on any given date




Codes 99358 and 99359 are used when a physician provides prolonged service not involving direct (face-to-face) care that is beyond the usual non-face-to-face component of physician service time.

This service is to be reported in relation to other physician services, including evaluation and management services at any level. This prolonged service may be reported on a different date than the primary service to which it is related. For example, extensive record review may relate to a previous evaluation and management service performed earlier and commences upon receipt of past records. However, it must relate to a service or patient where direct (face-to-face) patient care has occurred or will occur and relate to ongoing patient management. A typical time for the primary service need not be established within Procedure code set.

Codes 99358 and 99359 are used to report the total duration of non-face-to-face time spent by a physician on a given date providing prolonged service, even if the time spent by the physician on that date is not continuous. Code 99358 is used to report the first hour of prolonged service on a given date regardless of the place of service. It should be used only once per date.

Prolonged service of less than 30 minutes total duration on a given date is not separately reported.

Code 99359 is used to report each additional 30 minutes beyond the first hour regardless of the place of service. It may also be used to report the final 15 to 30 minutes of prolonged service on a given date.

Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.

Do not report 99358-99359 for time spent in medical team conferences, on-line medical evaluations, care plan oversight services, anticoagulation management, or other non-face-to-face services that have more specific codes and no upper time limit in the Procedure code set. Codes 99358-99359 may be reported when related to other non-face-to-face services codes that have a published maximum time (eg, telephone services).

99358 Prolonged evaluation and management service before and/or after direct (face-to-face) patient care; first hour

99359 Prolonged evaluation and management service before and/or after direct (face-to-face) patient care;each additional 30 minutes (List separately in addition to code for prolonged physician service) (Use 99359 in conjunction with 99358)

Prolonged Physician Service

If chart notes are not submitted for Prolonged Services, the claim will be processed as provider write-off with the explanation code stating that supporting documentation is required.

Insurance will reimburse for prolonged physician services with direct face-to-face patient contact that require a minimum of 30 minutes beyond the usual service. “Prolonged services” are limited to include the procedure codes 99354 through 99357.

• Prolonged services charges must be billed with an E/M code in which time is a factor in determining the level of service.

• Prolonged service charges are not reportable with non-time based procedures codes such as surgery or maternity. Other non-covered services include, but are not limited to:

— Neuropsychological and behavioral testing

— Intubation

— Bronchoscopy

— CPR

— Infusion/chemo administration

— Anytime spent performing and documenting separately reportable services

• The time for usual service refers to the typical/average time units associated with the companion evaluation and management (E/M) service.

• Prolonged services cannot be billed if separately reportable services were performed.

• Office visits that consist of 50% or more counseling and exceed the usual time for the E/M must first be billed to the highest level in the given E/M group (new patient, established patient) before the prolonged service can be billed. In this circumstance, time is the deciding factor in choosing the appropriate E/M code.

• Physicians may count only the duration of direct face–to face contact between the physician and patient, whether the service was continuous or not.

• For inpatient settings, the physician cannot bill prolonged services for the time spent waiting for lab results, reviewing charts, etc.

• Services rendered during the prolonged portion of the visit must be coverable on the member’s policy. For 78 Insurance Health Plans Revised September 9, 2016. Replaces all prior versions.

If chart notes are not submitted for Prolonged Services, the claim will be processed as provider write-off with the explanation code stating that supporting documentation is required.