ED Coding and Reimbursement Alert

Question: We are trying to find a code or codes to use for patients who are awaiting transfer to another facility but are still provided with monitoring. The monitoring may be minimal or significant, depending on the circumstances. I understand that 99358 is used for reviewing extensive records, tests and communication for the first hour. But is the purpose of the 99359 code for the instances I am questioning? If a patient was waiting for three hours and 99358 is used, can we add 99359 times 5? What are the guidelines?

Kimberly A. Morosky, ART, CCS
Greene County Memorial Hospital
Waynesburg, Pa.

Answer: Prolonged physician service without face-to-face contact (99358-99359) is not covered by Medicare. For Medicare patients, these services are included in the payment for direct face-to-face services performed by the physician.

Commercial insurance payers or self-pay patients may be billed for prolonged physician services without direct face-to-face contact. These types of services include physician review of extensive records and tests or communication (other than telephone calls) with other professionals or the patients family. These services must be beyond the usual services offered to the patient. The codes are valid in inpatient and outpatient settings and should be reported in addition to the other services provided, including any level of evaluation and management (E/M) service. Code 99358 is used to report the first hour, and 99359 is used to report each additional 30-minute period. For example, services lasting less than 75 minutes would be billed with only 99358. Services lasting between 75 and 104 minutes would be billed with 99358 and one unit of 99359.

In the case of a patient receiving minimal monitoring for an extended period of time, I would hesitate to bill the prolonged services codes. The patients diagnosis and status would have to provide adequate medical necessity to be considered to be beyond the usual service. The time spent monitoring the patient must be documented. A patient receiving significant monitoring by a physician while waiting for transfer probably would have an appropriate diagnosis and status to establish medical necessity to justify the use of the codes. The physicians documentation must support that the services performed were required and went beyond the usual services provided to a patient in that situation. The time spent monitoring the patient also should be documented specifically. Be prepared to provide supporting documentation to the carrier for all of the service provided. You also may want to review any insurance contracts that you have to verify whether this is a billable service under your agreement.