CMS New Coverage of Prolonged Services

Report Prolonged Services with E/M Codes

The Centers for Medicare & Medicaid Service

(CMS) typically does not allow separate payment for physician services that do not require face-to-face time with a patient. As of Jan. 1, 2017, CMS has made an exception and will now allow Medicare coverage for non face-to-face prolonged service codes 99358 Prolonged evaluation and management service before and/or after direct patient care; first hour and +99359 …each additional 30 minutes (List separately in addition to code for prolonged service), in compliance with CPT® guidelines.

Source: CMS Transmittal 3678, Change Request 9905 (Dec. 16, 2016)

CPT® Evaluation and Management/Prolonged Services instructions dictate:

"Codes 99358 and 99359 are used when a prolonged service is provided that is neither face-to-face time in the office or outpatient setting, nor additional unit/floor time in the hospital or nursing facility setting during the same session of an evaluation and management service and is beyond the usual physician or other qualified health care professional service time."

Codes 99358 and 99359 are to be reported in addition to other E/M service codes, to which they relate. “For example,” CPT® explains, “extensive record review may relate to a previous evaluation and management service performed earlier and commences upon receipt of past records.”

In keeping with CPT® requirements, CMS stresses, “codes 99358 and 99359 cannot be reported during the same service period as complex chronic care management (CCM) services or transitional care management services. They are not reported for time spent in non-face-to-face care described by more specific codes having no upper time limit in the CPT code set.” CMS further stipulates, “99358 and 99359 can only be used to report extended qualifying time of the billing physician or other practitioner (not clinical staff).”

Codes 99358 and 99359 are time-based and include “the total duration of non-face-to-face time spent by a physician or other qualified health care profession on a given date providing prolonged services, even if the time… is not continuous,” according to CPT®. The codes are applied as follows:

Total duration of services Coding

< 30 minutes Not reported separately

30-74 minutes 99358

75-104 minutes 99358, 99359

105-134 minutes 99358, 99359 x 2

Documentation should summarize the necessity and specific content of the prolonged services.