by Wyn Staheli, Director of Content - innoviHealth
and Aimee L. Wilcox, CPMA CCS-P CST MA MT
Jun 3rd, 2021
Due to the extensive changes in office or other outpatient services (99202-99215), there are many questions which still need to be answered, one of which is related to the prolonged services without face-to-face contact. This article explores the question regarding the appropriate use of codes 99358/99359 and how to report it in relation to office or other outpatient E/M services (99202-99215). To answer this question, we will evaluate different published statements and guidelines. Please keep in mind that it is critical to know payer-specific policies for these codes and whether or not the payer has officially adopted the CPT codebook guidelines as published by the American Medical Association. Identify payers with whom you are contracted and determine which guidelines they are following for 99202-99215 and whether they have any additional rules regarding the reporting of 99358/9.
Note: The CPT Assistant and CPT Changes are considered the AMA’s opinion on the codes and descriptions. As mentioned above, payers (e.g., CMS) may publish policies which are different from information contained in those publications, and if contracted with them, the provider is obligated to abide by those payer-specific policies.
CPT Codebook Guidelines
The official 2021 CPT codebook guidelines indicate that an extensive record review related to an E/M service that has or will occur may qualify for reporting these prolonged code. It states:
This service is to be reported in relation to other physician or other qualified health care professional services, including evaluation and management services at any level. This prolonged service may be reported on a different date than the primary service to which it is related. For example, extensive record review may relate to a previous evaluation and management service performed at an earlier date. However, it must relate to a service or patient where (face-to-face) patient care has occurred or will occur and relate to ongoing patient management.
Codes 99358 and 99359 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 providing prolonged service, even if the time spent by the physician or other qualified health care professional on that date is not continuous.
As noted above, the code description identifies 99358 as a prolonged service code that correlates to an E/M service (before, on the same day [except 99202-99215], or after) direct patient care. Because 99358 is NOT an add-on code, it may be reported alone but the documentation must identify it as related to an E/M encounter.
Code 99358 may be reported in addition to any level of E/M service in the outpatient, inpatient, or observation setting (e.g., 99231, 99213, 99244), except 99211 and must be performed by a physician or other qualified healthcare professional (QHP).
Coding Tip: Do not report 99358, 99359 for a prolonged service related to 99202-99215 on the same day as the E/M service. Code 99417/G2212 is reported exclusively for prolonged services on the same day as 99202-99215 and is ONLY reported with 99205 or 99215. If the prolonged service (99358) occurs on a date other than the day the E/M service was performed, it may be correlated with any level of E/M service (99202-99215).
Report 99358 for the first hour of prolonged service time once a minimum of 30 minutes has been completed. For prolonged services that extend beyond one hour, add-on code 99359 may be reported for each additional 15-30 minutes beyond the first hour. Documentation in the medical record should include the time (i.e., total time or start/stop) and a summary of the E/M-related service performed.
Prolonged service code 99358 may be reported for work that correlates with an E/M encounter from another date, including 99202-99215 when the original E/M service code was determined based on MDM instead of time. As a stand-alone-code, 99358 is based on time spent performing the prolonged service, unrelated to the time spent performing the related E/M encounter. For example, if on Tuesday the provider documented data that supports an MDM level 99213 (not based on time) and on Wednesday, the provider finally receives the medical records for the patient he saw the day before and spends 47 minutes reviewing and summarizing them, the codes reported would be 99213 for Tuesday and 99358 for Wednesday.
Scenario: The provider requested copies of the patient’s medical records from a previous surgeon but by the appointment time they had still not arrived. The E/M service was completed and scored based on MDM and a total time of 22 minutes was documented. Later the same day, the medical records arrive and the provider spends 47 minutes reviewing and summarizing them and makes adjustments to the patient’s medications based on the record review.
Scoring: The medical records review cannot be reported with 99358, as it was performed on the same day as the E/M encounter reported with 99213. As such, the provider may only report 99417 or G2212 for the additional time as long as the encounter meets qualification for code 99215 because those are the codes which are exclusively used to report same day prolonged services.
The 47 minutes spent on records review/summary is added to the total time (22 minutes) spent on the E/M encounter, making a total time of 69 minutes, which changes the E/M code from 99213 to 99215 based on time. The time range associated with 99215 is 40-54 minutes. If the payer follows CPT codebook guidelines, the provider may report one unit of 99417 once 15 minutes beyond the lower number in the time range (40) has been reached (40+15=55 minutes). To report a second unit though, the time would have to be a total of 70 minutes. However, if the payer follows Medicare guidelines, code G2212 may be reported once 15 minutes beyond the upper end of the time range (55 minutes) has been reached (55+15=70 minutes). In this scenario, if the payer followed Medicare guidelines, they would not qualify to report G2212 and the additional time spent would only be reflected in the increase from 99213 to 99215.
If the service, however, had been a consultation and reported with 99243 based on MDM, the prolonged time spent performing the record review of 47 minutes technically could be reported as one unit of 99358, allowing additional compensation.
This is a great example of why understanding and correctly following the specific payer guidelines is important.
Other AMA Information
The CPT Assistant is considered a secondary source of guidance to the CPT codebook guidelines, and is published by the AMA. At the time of publication of this article, the most current CPT Assistant available on these codes was published in September 2020, so keep in mind that any other changes made to the CPT codebook guidelines in 2021 might not be reflected in the following statement (emphasis added):
Codes 99358 and 99359 are used when a prolonged service provided is neither face-to-face time in the outpatient, inpatient, or observation setting, nor additional unit/floor time in a facility or observation setting. Codes 99358 and 99359 may be reported on the same date as an E/M service, except office or other outpatient services (99202-99205, 99212-99215). Codes 99358 and 99359 may also be reported on a different date than the primary service to which it is related, including office or other outpatient services (99202-99205, 99212-99215). For example, extensive record review may relate to a previous office E/M service performed on an earlier date or an upcoming E/M service on a future date. The prolonged non-face-to-face patient care must relate to face-to-face patient care that has occurred or will occur and the care must relate to ongoing patient management. Codes 99358 and 99359 are used to report the total duration of non-face-to-face time spent by the billing physician or other QHP on a given date providing prolonged service, even if the time spent by the physician or other QHP on that date is not continuous. Code 99358 is used to report the first hour of prolonged service on a given date regardless of the place of service and may only be reported once per date.
At the beginning of the CPT Assistant, there is a disclaimer which states that “[u]sers should consult the CPT 2021 code set for the final code numbers, descriptors, and guidelines language. Furthermore, the calendar year (CY) 2021 physician fee schedule (PFS) proposed rule, released August 3, 2020, introduces alternative interpretations to time reporting for the new prolonged service(s) code.” Those PFS alternative interpretations are discussed in the “CMS PFS Final Rule 2021” section below.
RUC Work Valuation
The concern that some auditors have expressed has to do with the valuation of the work component as defined by the CPT/RUC Workgroup. The Chairmen of the AMA CPT Editorial Panel and the AMA/Specialty Society Relative Value Update Committee (RUC) formed the CPT/RUC Workgroup which had the task of developing both the “coding structure for office visits to foster burden reduction, while ensuring appropriate valuation.” They stated in 2019 (emphasis added):
When codes are reported based on time, there are specific time requirements within each code descriptor (e.g., 45-59 minutes for 99204). The CPT time describes the total time devoted to the visit on the day of service (i.e., the sum of face-to-face and non-face-to-face physician or QHP time that day). Importantly, however, the work value for the code is based on the entire time spent by the physician from three days before the visit to seven days following the visit. The survey clarified this distinction throughout the survey. The Research Subcommittee approved the use of three days prior and seven days following the office visits based on instructions within CPT to not report certain non-face-to-face services that relate to office visit pre/post work (e.g., telephone services and inter-professional consultations).
The respondents agreed that the current times and work RVUs for every office visit code are too low. For most codes, the survey respondents indicated the time it takes to perform these services is 23%-38% longer than what is reflected in the Medicare Physician Payment Schedule. Consistent with the time increase the respondents also indicated that these services are undervalued by 13%-34%.
Keep in mind that although this information was released in 2019, it gives insight into how much work was considered inclusive to the work RVU of an Office/Outpatient E/M visit. There are several important things to note in this statement about how they valued the work involved.
- Codes are reported based on time and not MDM (and only time on the calendar day of the service)
- Total work is calculated to include 3 days before and 7 days after the intraservice time of the related E/M encounter
- Only telephone and inter-professional consultations include the description excluding work related to an E/M encounter that is within 3 days prior or 7 days after it
- Services have been undervalued
So just how much extra time did they include as part of pre-service and post-service time in that 3 days before and 7 days after the related E/M visit window? Their recommendations were included in the 2021 Medicare Physician Fee Schedule Proposed Rule as follows:
Actual Total Time
RUC-recommended Total Time
Looking at the pre-service and post-service times, it is clear that time spent far beyond these times could justify the reporting of prolonged service codes, as applicable.
CMS PFS Final Rule 2021
Now that we know what the AMA has officially stated about these services, we need to look at what CMS stated in the 2021 Final Rule about these codes (emphasis added).
Given the lack of clarity provided by commenters on the CY 2020 PFS proposed rule about why the sum of minutes in the components would differ from the total minutes, and our view and systems requirement that total time must equal the mathematical total of component times, we proposed beginning in CY 2021 to adopt the actual total times (defined as the sum of the component times) rather than the total times recommended by the RUC for CPT codes 99202 through 99215.
We continue to believe that it would be illogical for component times not to sum to the total, and we reiterate that our ratesetting programs are constructed in a manner that assumes this. While we recognize the value of robust survey data, for purposes of consistency and relativity, we believe we should use a consistent methodology across the fee schedule. Also it is not clear why the RUC surveyed time before and after the date of service since the new CPT coding guidance instructs practitioners to report this time using CPT codes 99358 and 99359 (although CMS will no longer recognize 99358–99359 for this purpose, for reasons discussed elsewhere in this section). Having considered the public comments received, we are finalizing our proposal to adopt the actual total times (defined as the sum of the component times) rather than the total times recommended by the RUC for CPT codes 99202 through 99215.
Regarding prolonged visits, we finalized separate payment for a new prolonged visit add-on CPT code (CPT code 99XXX), and discontinued the use of CPT codes 99358 and 99359 (prolonged E/M visit without direct patient contact) to report prolonged time associated with O/O E/M visits. We refer readers to the CY 2020 PFS final rule for a detailed discussion of this policy (84 FR 62849 through 62850). We are not opposed in concept to reporting prolonged office/outpatient visit time on a date other than the visit, but we believe there should be a single prolonged code specific to O/O E/M visits that encompasses all related time.
This statement brings up the fact that the RUC table of recommended times for the components of pre-, intra-, and post-service doesn’t necessarily add up.
CMS also questioned the RUCs use of the 3 days before (pre-service) and 7 days after (post-service) to be included in the valuation of the codes, which seems to contradict the CPT codebook guidelines indicating 99358/99359 should be reported for an extended medical record review the day prior to or following a related E/M encounter. According to the above CMS statement, they do not recognize reporting 99358/99359 for prolonged services related to office or other outpatient (O/O) E/M visits (99202-99215), but they also do not specify what they consider to be pre- and post-service work nor mention how to handle it when prolonged services are on a different day and related to the E/M visit. At this time, we haven’t been able to find any statements about what CMS considers pre-service and post-service other than the table published in the 2021 Proposed Rule.
In summary, it comes down to what the payer considers bundled into the E/M service and if they adhere to the RUC workgroup’s stated 3-day pre-service and 7-day post-service inclusion period in which certain E/M-related services (e.g., call with test results, order medications, order new tests, confer with another provider, review medical records) are performed. Therefore, based on all the presented information, unless a payer states otherwise, according to CPT codebook guidelines, codes 99358/99359 may be reported as long as the following are met:
- Time requirements have been met meaning that there has been at least 30 minutes of non-face-to-face services (e.g., extensive record review and summary)
- The service is related to another E/M visit that has happened or will happen
- Time also exceeds the RUC time recommendations as shown in the table above for an O/O E/M
As always, the documentation must support the time spent performing non-face-to-face services.
About Wyn Staheli, Director of Content - innoviHealth
Wyn Staheli is the Director of Content Research for innovHealth. She has over 30 years of experience in the healthcare industry. With her degree in Management Information Systems (MIS), she has been a programmer for a large insurance carrier as well as a California hospital system. She is also the author and editor of many medical resource books and the founder of InstaCode Institute.