Gastroenterology Coding Alert

Question: We are hoping to bill a private payer for a prolonged service but we didn't see the patient face-to-face. Can we report 99358 (Prolonged evaluation and management service before and/or after direct patient care; first hour)?

Codify Subscriber

Answer: CPT^® guidelines for reporting prolonged service codes are very strict. To use 99358, the non-face-to-face service must "relate to a service or patient where (face-to-face) patient care has occurred or will occur, and relate to ongoing patient management," according to CPT® instruction.

Clarify: The guidelines also state that you cannot report these codes for "time spent in care plan oversight services ... home and outpatient INR monitoring ... medical team conferences ... on-line medical evaluations ... or other non-face-to-face services that have more specific codes and no upper time limit."

That means you might be able to use the codes if you can document "prolonged communication consulting with other health care professionals related to ongoing management of the patient, or prolonged review of extensive health record and diagnostic tests regarding the patient," according to CMS guidelines for 99358/+99359. You must also document the additional 30-74 minutes for 99358.

Always document the time duration of the service and what services you provided. For example, the notes might say, "I spent 55 minutes reviewing Mr. Adams' previous tests, records, reports, and notes from his prior visits. I spoke with the physician who performed her colon cancer treatment and reviewed the records he sent."