Regarding non face-to-face prolonged care, does Medicare require start and stop times, they way they do for prolonged face-to-face care? As long as the provider documents the total time spent reviewing old records is sufficient to bill this service, am I correct? (Codes 99358, 99359)
Neither CPT® nor CMS require start and stop times. I was shocked to read the CMS manual and not see start/stop times, since they require them for face-to-face prolonged care. Sometimes, there is no understanding the “why,” is there?
And, from the Medicare Claims Processing Manual, 100-04, Chapter 12
126.96.36.199 – Prolonged Services Without Direct Face-to-Face Patient Contact Service (Codes 99358 – 99359) (Rev. 3678, Issued: 12-16-16, Effective: 01-01-17, Implementation: 01-03-17)
Until CY 2017, CPT® codes 99358 and 99359 were not separately payable and were bundled (included for payment) under the related face-to-face E/M service code. Practitioners were not permitted to bill the patient for services described by CPT® codes 99358 and 99359 since they are Medicare covered services and payment was included in the payment for other billable services.
Beginning in CY 2017, CPT® codes 99358 and 99359 are separately payable under the physician fee schedule. The CPT® prefatory language and reporting rules for these codes apply for Medicare billing.
For example, CPT® 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.
We have posted a file that notes the times assumed to be typical for purposes of PFS rate-setting. That file is available on our website under downloads for our annual regulation at http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
We note that while these typical times are not required to bill the displayed codes, we would expect that only time spent in excess of these times would be reported under CPT® codes 99358 and 99359.
We note that CPT® codes 99358 and 99359 can only be used to report extended qualifying time of the billing physician or other practitioner (not clinical staff).
Prolonged services cannot be reported in association with a companion E/M code that also qualifies as the initiating visit for CCM services. Practitioners should instead report the add-on code for CCM initiation, if applicable.
Change in rules for codes 99358, 99359 in 2021
These are still active codes in 2021, however, they may not be reported on the same day as office/outpatient codes 99202–92915. They may be reported on days prior to or after a visit, or on the same day as other E/M services. See the CodingIntel page on E/M Changes for 2021 for more details.