Neurology & Pain Management Coding Alert

Question: Does CPT code 99359 need to be listed separately for each unit, and should a -51 modifier be appended after the primary procedure code for Medicare?

Theodore Nukes, MD
Lafayette, Ind.

Answer: The prolonged service codes should be used when a physician provides care not involving direct (face-to-face) contact that is beyond the usual service in either the inpatient or outpatient setting, says Linda Jackson, CCS-CPC, Medicare consultant at Iowa Veterans Home, Marshall Town, Iowa. This service is reported in addition to other physician services, including evaluation and management (E/M) services at any level.

Use code 99358 (prolonged E/M service before and/or after direct [face-to-face] patient care [e.g., review of extensive records and tests, communication with other professionals and/or the patient/family]; first hour, [list separately in addition to code(s) for other physician service(s) and/or inpatient or outpatient evaluation and management service]) to report the first hour of prolonged service on a given date regardless of the place of service. It also may be used to report a total duration of prolonged service of 30 to 60 minutes on a given date. It should be used only once per date, even if the time spent by the physician is not continuous on that date.

Code 99359 (prolonged E/M service before and/or after direct [face-to-face] patient care [e.g., review of extensive records and tests, communication with other professionals and/or the patient/family]; each additional 30 minutes [list separately in addition to code for prolonged physician service]) is used to report each additional 30 minutes beyond the first hour regardless of the place of service. It also may be used to report the final 15-30 minutes of prolonged service on a given date.

Please note that 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.

For example:
30-74 minutes would be: 99358 x 1 Unit
75-104 minutes would be: 99358 x 1 and 99359 x 1
105-134 minutes would be: 99358 x 1 and 99359 x 2
135-164 minutes would be: 99358 x 1 and 99359 x 3

Jackson reports that there is no need to use a -51 modifier (multiple procedures). Although the -51 modifier indicates that multiple procedures are performed other than E/M services by the same provider at the same session, it is not necessary or appropriate for use with these prolonged service codes.