Wiki Documentation Guidelines for 99358 and 99359

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Bilodeau

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Codes 99358 and 99359 are monitoring codes. We are going to be giving our patients a new medication (FDA approved) for MS. When a patient is given this drug they are to be monitored for 6 hours. These are the 2 codes I came up with for the monitoring. I have been unable to find any documentation guidelines for these two codes. I need documentation guidelines for these codes and if there are any references for the guidelines.
 
99358-9 are not monitoring codes. These are physician codes to be used when the provider is not face to face but is addressing the patient's issues in some way such as over the phone or with other caregivers when the patient is not there. For the patient to remain in the office for 6 hours and have someone check on them periodically is not proper use of this code. If the physcian evaluates the patient prior to administering the drug then you possibly have a visit level, then if he documents time spent with the patient during the initial eval plus any face to face time spent checking on the patient then you may have enough time to add on a prolonged face to face code.
 
mitchellde said:
99358-9 are not monitoring codes. These are physician codes to be used when the provider is not face to face but is addressing the patient's issues in some way such as over the phone or with other caregivers when the patient is not there. For the patient to remain in the office for 6 hours and have someone check on them periodically is not proper use of this code. If the physcian evaluates the patient prior to administering the drug then you possibly have a visit level, then if he documents time spent with the patient during the initial eval plus any face to face time spent checking on the patient then you may have enough time to add on a prolonged face to face code.
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The physician is giving the patient a drug for the first time and the patient has to be monitored for the 6 hours. The patient will be monitored for signs and symptons of bradycardia. I am not sure if the physician or a nurse will be checking on the patient. If the nurse is the one checking on the patient, what codes should be used?
 
If the nurse is checking on the patient then it is not billable. If it is the physician then he must document the amount of time for each time he checks the patient face to face and the assessment each time. Then you will need to evaluate the entire amount of time spent and the actual visit level to see if a 99354 can be added to the visit level.
 
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