Neurosurgery Coding Alert

Check if service qualifies for another E/M code; count only physician services.

This year brings in the dawn of some E/M reforms. You have a different set of add-on codes that you can try to report for prolonged services that your physician performed when they are not face-to-face with the patient. These add-on codes are:

• 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]).

As with face-to-face prolonged care services, you should report the code 99358 for the first hour of non-face-to-face services that your physician provides to the patient and then report +99359 for every additional 30 minutes of service beyond the first hour.

Trends in 2016: Until now, Medicare has not been paying separately for 99358 and +99359. These services have been part of the related face-to-face E/M service codes.

New in 2017: Effective Jan 1, 2017, Medicare will separately pay for prolonged services without direct face-to-face patient contact. According to the MLN Matters^® Number: MM9905, these services are now separately payable under the physician fee schedule.

You can read more details on: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9905.pdf.

Update in the manual: You can locate this CMS revision in the Medicare Claims Processing Manual (Pub. 100-04, Chapter 12, Section 30.6.15.2).

99358 and +99359 May Not Always Apply

Watch out for the situations when you should not submit 99358 and +99359. These are typical situations of when you should turn to more definitive codes which will include the services described in 9938 and +99359.

1. You do not submit codes 99358 and +99359 in the same service period when you are reporting complex chronic care management and transitional care management services.
2. You do not submit codes 99358 and +99359 when you have more specific codes for the service without a time limit specified in the more definitive codes

Example: You cannot submit codes 99358 and +99359 with 99490 (Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements…). The services in 99358 are bundled into code 99490. Code 99358 is a column 2 code for 99490 and you cannot bill these codes together in any circumstances.

The same rules apply to codes 99495 (Transitional Care Management Services with the following required elements: Communication [direct contact, telephone, electronic] with the patient and/or caregiver within 2 business days of discharge Medical decision making of at least moderate complexity during the service period face-to-face visit, within 14 calendar days of discharge), and 99496 (…….within 7 calendar days of discharge).

Carefully Define What Your Physician Did

Before you bill the prolonged services codes, you should read the clinical note and confirm what services your physician provided. You do not report prolonged services with an E/M code that qualifies as the initiating visit for CCM services.

Example: When your physician decides to initiate CCM services during an inpatient E/M, you may bill the E/M for an inpatient hospital care with 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components… Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient’s hospital floor or unit). Since you have the code 99232 to precisely report the E/M, you do not submit the prolonged service codes with this 99232.

Eliminate Services of Clinical Staff

You can report the codes 99358 and +99359 only when the billing physician or another practitioner renders the services in the extended qualifying time in non face-to-face prolonged services. Unlike the chronic care management codes, for example 99490, the prolonged services codes 99358 and +99359 do not apply to the services offered by clinical staff.

Caveat: Many payers do not provide coverage for non-face-to-face prolonged care service codes, +99358 and +99359. Check payer policies and coverage guidelines to see if these services are covered before you report these codes.