Primary Care Coding Alert

Once you’ve answered the quiz questions, compare your answers with the ones provided below:

Answer 1:
CPT^® guidelines outline a number of restrictions on reporting 99358 and +99359. Specifically, the services must both:

• Relate to a service provided by “a physician or other qualified health care professional (QHP), including evaluation and management services at any level.”
• “Relate to a service or patient where (face-to-face) patient care has occurred or will occur and relate to ongoing patient management.”

“The prolonged services without patient contact codes must relate to a face-to-face service but do not need to be reported on the same date,” explains Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington. “In fact, they describe time spent preparing for a face-to-face visit, such as reviewing old medical records, or to follow up after a face-to-face visit, such as reviewing records received after the visit or contacting other providers to coordinate care,” Bucknam adds.

Additionally, the codes are used to:

• “Report the total duration of non-face-to-face time spent by a physician or other qualified health care professional on a given date … even if the time spent by the physician or other qualified health care professional on that date is not continuous.”
• “Report the first hour of prolonged service on a given date regardless of the place of service.”

Also, according to the Centers for Medicare & Medicaid Services (CMS), you can report 99358 and +99359 providing you can document “prolonged communication consulting with other health care professionals related to ongoing management of the patient, and prolonged review of extensive health record and diagnostic tests regarding the patient,” according to Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

Lastly, you should use prolonged services codes only once per date and only when the total duration of the services is 30 minutes or more. Per CPT^® guidelines, “prolonged service of less than 30 minutes total duration on a given date is not separately reported because the work involved is included in the total work of the evaluation and management or psychotherapy codes.” This means “time needs to be precise when reporting prolonged services,” advises Falbo.

Reporting the prolonged service codes, both those with and those without direct patient contact, requires provider education, because the medical documentation must be excellent, Bucknam says. This documentation must cover the services provided, the amount of time involved, and also the medical necessity for the prolonged services.

Answer 2:
CPT^® does not allow you to use 99358 and +99359 with care plan oversight services (99339, 99340, 99374-99380), home and outpatient international normalized ratio (INR) monitoring (93792, 93793), medical team conferences (99366-99368), or online medical evaluations (99444).

Additionally, you cannot report 99358 and +99359 with care management services during the same month. This includes behavioral health care management (99484), complex chronic care management (99487-99489), chronic care management (99490, 99491), and psychiatric collaborative care management (99492, 99493, +99494). And, if they are performed during the same service time, you cannot report 99358 and +99359 with transitional care management (99495 or 99496).

Answer 3:
In this particular scenario, you would report the appropriate new patient E/M service with 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient …). You would also report 99358 as the provider has spent a total of 45 minutes reviewing records before and after the encounter. Lastly, you would code for the developmental test using 96112 (Developmental test administration … first hour), adding +96113 (… each additional 30 minutes (List separately in addition to code for primary procedure) as appropriate.