The Physician and Non-Physician Fee Schedule effective March 1, 2017 – December 15, 2017 brought a variety of new CPT codes, including 99358 and 99359, into effect in California. Both of these codes allow physicians or nonphysician practitioners to bill for prolonged services that are not face-to-face.
Non-Face-to-Face Codes Are Now Billable
Some patients require additional non-face-to-face care and their providers deserve to be paid for that care. Medicare now acknowledges this. The introduction of CPTs 99358 and 99359 as reimbursable codes on March 1, 2017, creates an opportunity for reimbursement for the additional work required for workers' comp patients. The services covered by these codes were often provided for free; that they are now billable is a boon to providers across the state.
Say a provider agrees to treat a new workers’ comp patient. To better inform their treatment, this provider is sent old medical records. These records are disorganized, perhaps incomplete, and contain multitudes of irrelevant information that has no direct bearing on the current case. So the provider digs in and studies the information on his or her own time, sifting through the records to uncover any pertinent information. They are undeniably providing a service—a better-informed provider will create a better treatment plan—but, until now, this sort of work has had no dedicated reimbursement amount.
Not anymore. Starting on March 1, 2017, workers’ comp providers can bill for prolonged non-face-to-face services using the following CPT codes:
- 99358 – Prolonged evaluation and management service before and/or after direct patient care; first hour
- 99359 (add-on code) – Each additional 30 minutes (List separately in addition to code 99358 for prolonged service)
Limitations on Billing Non-Face-to-Face Codes
As with all other CPT codes with a strictly-defined time component, the provider must meet over half of the specified time before billing. In this case, that means that a provider must spend 31 minutes or more before billing code 99358, and 76 minutes or more before adding code 99359.
As of April 1, 2017, you can bill a maximum of two hours of non-face-to-face time using CPT Codes 99358 and 99359 on any given day. There was previously no limit to the amount of non-face-to-face time that could be reported.
CPT 99444 for non-face-to-face online medical evaluation is incompatible with codes 99358 or 99359. You may not report them in conjunction. For more information about incompatible codes, download our Resource Notebook below. These codes do not apply to medical-legal bills and, therefore, cannot be applied to Qualified Medical Evaluators (QMEs) either.
There are no specific requirements for prolonged services. Though it is not required, we strongly recommend including supporting documentation when prolonged services are rendered. We included a sample Supporting Document Checklist as a guideline for providers in our Resource Notebook below.
Appealing Denial of Code 99358
If a claims administrator denies a bill using CPT Code 99358 claiming that it is not reimbursable, an appeal can be filed. Refer the claims administrator to the AMA CPT definition of 99358: Prolonged evaluation and management service before and/or after direct patient care; first hour. For dates of service on or after 3/1/2017 RBRVS indicate 99358 with a payment status code of "A" payable. Ask them to please pay accordingly.
99358: May be reported on a different date than the primary service to which it is related. Must relate to a service or patient where (face-to-face) patient care has occurred or will occur and relate to ongoing patient management. Does not need to be continuous. Time can not be counted more than once towards the provision 99358 and any other PFS service.
You need to spend at least 31 minutes of time to bill the first hour (99358) of prolonged time.
99359: You need to spend at least 76 minutes to bill the first hour plus an additional 30 minutes (+99359) of prolonged time.
Webinar and e-Booklet: CPT Codes 99358 & 99359
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