Orthopedic Coding Alert

Know how to capture work that occurs beyond the patient encounter.

Every coder knows how vital counting face-to-face time with patients is to the coding of each encounter.

However, providers also spend a lot of time doing the behind-the-scenes work that comes with healthcare but doesn’t involve patients directly: chart reviews, data analysis, etc. Even though this work doesn’t involve interacting with patients face-to-face, you may still be able to demonstrate that your providers have earned payment.

Check out these best practices for capturing these aspects of your providers’ routines.

Bad Idea: Using 99358/+99359 With 99202-99215

When you need to report non-face-to-face time your provider spends documenting, reviewing patient charts, or performing any other task related to patient care outside of actually seeing the patient face to face, reach for 99358 (Prolonged evaluation and management service before and/or after direct patient care; first hour) and +99359 (… each additional 30 minutes …) depending on the amount of time spent.

But be sure to follow the CPT^® instruction not to report 99358 and +99359 on the same date of service as office and other outpatient visit codes 99202-99215.

Avoid +99417/G2212 Unless Encounter Meets This Criteria

When billing for non-face-to-face service time, you also can use +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)) or its Medicare equivalent G2212 (Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services …).

But you need to use these codes carefully. As their descriptors state, you should use the codes when a provider performs non-face-to-face services in addition to an office/outpatient evaluation and management (E/M) service, as the codes represent combined time with and without direct patient contact.

So, you can use +99417 only if you select an office visit code using time, and the prolonged time exceeds the minimum amount required to report the highest-level office/ outpatient E/M service by 15 minutes.

For example, 99205 (Office or other outpatient visit for the evaluation and management of a new patient…. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter) has a time range of 60-74 minutes. You can report one unit of +99417 at 75 minutes as it is 15 minutes beyond the minimum. The same requirements exist for G2212; however, you cannot report a unit of this code until reaching 15 minutes beyond the maximum time for 99205 and 99215 (for example, 89 minutes for a 99205).

Remember: Per the descriptors for +99417 and G2212 “you can count numerous activities, including any time the provider spends updating a patient’s clinical information in the record. But you can only do so providing they occur on the day of the visit,” according to Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

This is unlike 99358/+99359, which allow you to report the same activities when conducted during the same session of an E/M service (except for 99202-99215) or a date other than the date of a face-to-face encounter.

Document This Work Before Using 99358/+99359

First, even though 99358/+99359 do not have to be linked to a specific office/outpatient E/M service, they must “relate to a service or patient where (face-to-face) patient care has occurred or will occur and relate to ongoing patient management” per CPT^® guidelines. This means provider documentation must support the amount of time and purpose of the non-face-to-face activities before you can use the codes. Then you can use, for example, “prolonged reviews of extensive health records and diagnostic tests regarding specified patients and prolonged consultations with other healthcare professionals related to ongoing patient management,” to justify reporting 99358/+99359, according to Falbo.

Additionally, you can use 99358/+99359 for telephone conversations with a patient or the patient’s family if it satisfies the above criteria. But provider or other qualified healthcare professional (QHP) documentation must show that the provider or QHP initiated the conversation, per CPT^® Assistant (Volume 31, Issue 9, September 2021).

Also: Any time your provider or QHP initiates communication with the patient, family member, or even another healthcare professional, and the subject of the communication is the patient’s treatment or care management, you can use the time your provider spent in the communication toward the time billed with 99358/+99359.

But when the patient initiates the communication, you must document the encounter differently. For example, telephone codes 99441-99443 (Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service …) “are used to report episodes of patient care initiated by an established patient or guardian of an established patient” and cannot be used to document “a telephone discussion initiated by a physician or other QHP,” per CPT^® Assistant (Volume 31, Issue 9, September 2021).

Bad Idea: Double-Dipping on 99358/+99359

CPT^® also stresses that you cannot use 99358/+99359 to count “time without direct patient contact reported in other services, such as care plan oversight services … chronic care management by a physician or other qualified health care professional … home and outpatient INR monitoring … medical team conferences … interprofessional telephone/ Internet/electronic health record consultations … online digital evaluation and management services … or principal care management services.” The CPT® guidelines for 99358/+99359 have specific codes that you should report for these services instead of 99358/+99359 when appropriate.

Use 99358/+99359 for Non-Face-to-Face Longer Than 31 Minutes

Last, as with all time-based codes, you should “be aware of the different time thresholds” before using 99358/+99359, cautions Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “Prolonged physician or other QHP time of less than 30 minutes is not separately reportable,” Moore notes. So, while the time does not have to be continuous, you will have to meet the threshold of 30 minutes before coding 99358, and 75 minutes before using +99359 in addition to 99358.

Eye Units to Avoid Claim Delays

Finally, CPT^® requires you use 99358 “only once per date,” which does not have to be on the same date as any face-to-face service. So, providing you can satisfy all of these requirements, you can report your provider’s charting or chart review with 99358/+99359.

Caveat: Check with your private payers. “Third-party payer guidelines may differ from CPT^® coding guidelines, as both coverage and payment policy are determined by individual insurers or third-party payers. For reimbursement or third-party payer policy issues, contact the appropriate payer,” according to CPT^® Assistant (Volume 31, Issue 9, September 2021).