Are you getting paid for non-face-to-face prolonged care?

One of the most frequent complaints I hear from physicians is about the work done before and after an office visit, whether done the same day or another day. They say it is frustrating to spend so much time on those activities and receive no payment.

The Centers for Medicare & Medicaid Services (CMS) actually provided a bit of help in January although some practices may still not know about it. CMS created a set of CPT codes that allows physicians, physician assistants, and nurse practitioners to bill for non-face-to-face prolonged care of patients. Although any specialty physician can use these codes, CMS framed the change as a way to support primary care.

The codes are 99358 (Prolonged evaluation and management (E/M) 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).

This service must be related to a face-to-face E/M code, and it could be performed on the same day as the face-to-face service or on a prior or subsequent day. The 99358 code is not an add-on code so could be billed as the only service.  The 99359 code, on the other hand, is an add-on code to the first and must be billed on the same day as 99358. The code reflects time spent on care by the physician, NP, or PA, and does not cover office staff time. These codes are not used for typical pre- and post-visit work, such as reviewing your record or documentation after the visit.

The codes follow CPT time rules. The physician, NP, or PA must spend more than half of the required one hour to report the codes. So, for example, you would bill 99358 for visits of 30-74 minutes. But you would bill 99358 and +99359 for a visit of 75 minutes or more, with +99359 for each additional 30-minute increment.

These codes could be used for extensive record review or coordination of care. Make sure to document the time of the service and the work that was performed. For example, “I spent 45 minutes today reviewing Ms. Smith’s old records, prior to her visit.”

The national average reimbursement for 99358 is $113 with $55 reimbursed for each unit of 99359. That amount makes it worthwhile for most family physicians to submit claims for this service.

— Betsy Nicoletti, a Massachusetts-based coding and billing consultant