Medicare will pay for non-face-to-face prolonged services starting January 1, 2017 Codes: 99358 and 99359

Does this sound familiar? Before a visit with a new patient, the physician or non-physician practitioner receives old records. A stack of old records. And, these EHR printouts aren’t always organized in any way and frequently include pages and pages of non-information. (Don’t tell CMS we can’t send these electronically, but instead print the EHR record, mail it and then scan it into the next EHR.) What does the physician or NPP do? Now, spends his or her own time reviewing the records.

Starting January 1, that is a paid service, if it takes 31 minutes or more.

Truly, if the clinician meets half of the threshold time for the prolonged service without face-to-face contact (31 minutes), Medicare will pay. And the best part of this announcement: CMS will pay using CPT codes not HCPCS codes and follow CPT coding rules.

99358 Prolonged evaluation and management service before and/or after direct patient care, first hour

+ 99359 each additional 30 minutes (List separately in addition to code for prolonged services)

CPT Rules:

  • This service may be provided on the same day or on a different day than the face-to-face service.
  • It is for extensive time in addition to seeing the patient, and must relate to a service for a patient where direct face-to-face patient care has occurred or will occur and be part of ongoing patient management.
  • Code 99358 is not an add-on code. That is it can be reported on the day when no other service is provided.
  • Code 99359 is an add-on code to code 99358.
  • The time during the day a non-face-to-face service does not need to be continuous.
  • CPT tells us not to report these services during the same month as complex chronic care management (99487, 99489) or during the service time of transitional care management (99495, 99496).
  • You cannot double count the time for these non-face-to-face prolonged services codes and time spent in certain other activities represented by specific CPT codes. However, the list of CPT codes are mostly those which have a status either non-covered or bundled by Medicare. (Care plan oversight: 99339, 99340, 99374—99380; anticoagulant management: 99363, 99364, medical team conferences: 99366—99368, online medical evaluations: 99444, or other non-face-to-face services that have more specific codes and no upper limit in the CPT codes.

The example given in the CPT book is for extensive record review. However, there could be other coordination services that meet the requirements.

Because Medicare is following CPT rules for these services then the CPT rules related to time is in effect. I always think this is a “through the looking glass rule.” However it is a well-established CPT principle. For a service defined with a time component, the clinician must meet over half of the time stated. In the introduction in your CPT book under the heading time it states “A unit of time is attained when the mid-point is passed. For example, an hour is attained when 31 minutes have elapsed (more than midway between zero and sixty minutes). A second hour is attained when a total of 91 minutes have elapsed.” In the case of these non-face-to-face prolong surfaces that means that 99358 maybe reported when 31 minutes have been spent. In order to report the add-on code 99359, 76 minutes would need to be spent in the non-face-to-face prelaunch services work. There is no provision or splitting this work over to calendar dates. This time rule does not relate to the stated times for E/M services.

Neither CPT (nor Medicare in their final rule) limits the specialty of physician or NPP who can perform these services. Although CMS discusses it in the section related to improving payment accuracy for primary care, there is no prohibition for other specialties using these codes. These codes could be relevant for any physician or NPP who needs to review extensive records prior to a patient visit when the time reaches the 31 minute threshold.

And of course, document time in the medical record and briefly describe the work that was done.

January 24, 2017 I am giving a webinar “New revenue opportunities for primary care in 2017.” Check back: I’ll post an announcement about registering in late December.




4 thoughts on “Medicare will pay for non-face-to-face prolonged services starting January 1, 2017 Codes: 99358 and 99359

  1. The news about reimbursement for non-face-to-face services is fabulous. My major question is whether CMS has stipulated which type of services are eligible. The blog post makes it sound as if only record review is covered. Would a prolonged telephone discussion or a family meeting or coordination of care with specialists, etc. also be covered? Or is anything that we document that takes more than 31 minutes covered?

    • I went back and looked at the CPT book, the 2010 and 2012 CPT Changes an Insider’s View and the CMS 2017 Final Rule. The example in CPT is for medical record review, but it isn’t limited to record review. That is, it doesn’t say that is the only activity that may be counted. The Final Rule says, “such as extensive medical record review, review of diagnostic test results or other ongoing care management work.” CMS emphasizes that a physician/NP/PA can’t double count time for care plan oversight, use it in the same 30 day period as TCM or bill with complex chronic care management codes. There is no prohibition in billing it during a month when billing chronic care management 99490. And, that the work is work that is not in the scope of clinical staff.

      I would answer your question as yes. Prolonged phone calls, family meetings or coordination of care would qualify, as I read the CPT rules and CMS commentary. The work must be done on a single calendar day, but does not need to be continuous. Document the activity and the time.

  2. Any examples of what services might apply in the inpatient setting? Would frequent overnight calls from the ER or floor on critical patient updates qualify?

    • Please see the answer to Dr. Neilley’s question in the comments. Neither CMS nor CPT give any examples of the extra work for inpatient services or what would be considered part of pre/post work for an inpatient visit. Non-face-to-face prolonged services are allowed on the same day or a different day from an E/M service, and the E/M service could be office/outpatient or inpatient. In an inpatient setting, certainly extensive record review and review of diagnostic test results counts. CMS also gives the example of “other ongoing care management work.”

      I can’t answer definitively yes or no about calls related to critically ill patients.

      The time threshold of 31 minutes would need to be met for a single patient in a calendar day.

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