Pediatric Coding Alert

You can report extra time for extended visits with parents.

Although you’re familiar with prolonged service codes as a way to account for time spent “face-to-face” with a patient, there is also a set of codes for reporting extra time spent out of the patient’s presence on an E/M service—and every pediatric practice should know how to report them.

In some cases, a pediatrician may spend time away from the patient that still technically qualifies as a prolonged service -- such as when reviewing extensive records or discussing particulars of a patient’s case with other pediatricians or parents. When the physician provides non-face-t-face prolonged services of this sort, you’ll report:

• +CPT® 99358 -- Prolonged evaluation and management service before and/or after direct  patient care; first hour
• +CPT® 99359 -- ... each additional 30 minutes (list separately in addition to code for prolonged physician service). 

Example: You’re seeing a child for the first time who is a recent graduate of the NICU and has multiple problems including Down Syndrome and ventricular septal defect leading to congestive heart failure. You spend 30 minutes reviewing extensive records prior to seeing the patient, complete a 99205 initial patient E/M visit, and 15 minutes talking to the patient’s neonatologist and cardiologist. In this case, you should report 99205 and +99358 for the visit. This does not require the use of a modifier.

“Codes 99358 and 99359 are used when a prolonged service is provided that is neither face-to-face time in the office or outpatient setting, nor additional unit/floor time in the hospital or nursing facility setting during the same session of an Evaluation and Management service and is beyond the usual physician or other qualified health care professional service,” the August 2012 CPT® Assistant said. “These services may consist of, but not limited to, prolonged communication consulting with other health care professionals related to ongoing management of the patient, evaluation and management service performed earlier on the patient, or prolonged review of extensive health record and diagnostic tests regarding the patient.”

When you’re calculating the time spent for prolonged service coding, the time you document in your records must be extremely precise, CPT® Assistant advises. Therefore, your documentation should include how much time was spent performing each activity, what was discussed, and who the pediatrician communicated with during the conversations. 

Check Payer Policies

Unfortunately, not all insurers reimburse for these codes. Aetna’s policy, for instance, states, “Aetna does not pay for medical services without direct patient contact; thus, procedure codes 99358 and 99359 will be denied.”

Other payers have very specific criteria about when these codes are payable. For example, UnitedHealthcare doesn’t reimburse 99358 and 99359 in most situations, but the insurer will pay for these services for behavioral health providers in some states.

Because of these differences between payers, be sure to obtain your insurer’s policy in writing before you report these codes.