When your E/M visit lasts longer than expected and you want to account for your provider’s additional time, you might reach for a prolonged service code. Just be sure to double-check which code pairs you report together, because the recovery audit contractors (RACs) are watching.
Background: Earlier this year, Part B RAC Cotiviti added a new issue to its “Active Review” list involving the use of prolonged service codes 99358 and 99359. “Do not report CPT codes 99358 and/or 99359 during the same calendar month as CPT codes 99484, 99487, 99489, 99490, 99491, 99492, 99493 or 99494,” Cotiviti says.
To understand why auditors are watching prolonged services and what you can do to avoid problems, check out a few essential strategies.
99358-99359 Are for Non-Face-to-Face Prolonged Services
The codes that RACs are reviewing haven’t been payable by Medicare for long—in fact, CMS only began paying these codes in 2017:
- 99358: Prolonged evaluation and management service before and/or after direct patient care; first hour
- 99359: … each additional 30 minutes (List separately in addition to code for prolonged service)
You can collect for 99358 as long as the provider spends at least 31 minutes beyond the standard face-to-face time on responsibilities directly related to the E/M service. The provider must document what they did during the extra time, why they spent more time with the patient than what was allotted during the E/M visit time and specifically how many extra minutes they spent.
Avoid 99358-99358 With Office-Based E/Ms
Although 99358-99358 can be used with a wide variety of E/M codes, they aren’t allowable with the office/outpatient services codes (99202-99215).
You’ll find quite a few other prolonged service codes that are reportable with office visits, such as 99417 (Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes of total time (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services).
The RACs Are Seeking Violations to CPT Rules
Although the recovery audit contractors have added this as a new issue for 2023, the actual rationale behind it is not new. CPT® has always forbidden coders from reporting 99358 and 99359 with the codes for care plan oversight services, chronic care management, home and outpatient INR monitoring, medical team conferences, interprofessional telephone/Internet/electronic health record consultations, online digital evaluation and management services and principal care management services.
Here’s why: Those codes already include the work involved in non-face-to-face services, and to bill the prolonged service codes separately would be considered double dipping.
Report 99358 Just Once Per Date
The coding rules for 99358 indicate that you should only report it once per date of service. You’ll report 99358 to reflect the first hour after the time listed in the E/M code, and then 99359 for every 30 minutes beyond that first hour. You can report 99359 more than once if you have multiple units beyond the first 90 minutes of prolonged services, as long as your documentation supports that extra time.
Example: Putting it All Together
Suppose the physician sees the patient in the hospital for an inpatient E/M visit. The provider spends 90 minutes with the patient, and an additional 35 minutes on non-face-to-face activities, including meeting with other providers about the patient’s care. The patient is admitted and discharged on the same date.
In this situation, you’ll report one unit of 99236 (Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 85 minutes must be met or exceeded) and one unit of 99358 to reflect the extra 35 minutes.
Want more tips on how to report E/M services to collect all that you’re due? Check out expert strategies from Leonta Wiliams, RHIA, CCS, CCDS, CPC, CPCO, CEMC. During her one-hour training event, Earn More Money for Time-Based E/M Visits Without Getting Audited, Leonta will help you master the details you need to bring in every penny for your E/M Visits. Register today!
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