How To Use CPT Code 99358

CPT 99358 refers to prolonged evaluation and management services before and/or after direct patient care for the first hour. This article will cover the description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 99358.

1. What is CPT 99358?

CPT 99358 is a code used to report prolonged evaluation and management services performed by a healthcare provider before and/or after direct patient care. This code is applicable when the provider spends extra time in either preparation or evaluation of the outcome of treatment before or after a direct encounter with a patient. The code is used to bill for the first hour of such services, with a minimum of 30 minutes spent on the patient’s indirect care.

2. 99358 CPT code description

The official description of CPT code 99358 is: “Prolonged evaluation and management service before and/or after direct patient care; first hour.”

3. Procedure

1. Review of the patient’s medical records and test results.
2. Communication with other healthcare professionals involved in the patient’s care.
3. Discussion with the patient and/or their family regarding the treatment plan and progress.
4. Evaluation of the patient’s response to treatment and any necessary adjustments to the plan.
5. Documentation of the time spent on indirect patient care activities.

4. Qualifying circumstances

Healthcare providers who are eligible to bill for CPT 99358 services include physicians, nurse practitioners, and physician assistants. The prolonged evaluation and management services must relate to ongoing patient management or a patient where face-to-face patient care has been previously performed or will be performed. The provider must spend a minimum of 30 minutes on the patient’s indirect care for the first hour of service.

5. When to use CPT code 99358

It is appropriate to bill CPT code 99358 when the healthcare provider spends extra time on indirect patient care activities, such as reviewing extensive records, communicating with other professionals, and evaluating the patient’s progress. This code should be used for the first hour of such services, with a minimum of 30 minutes spent on the patient’s indirect care.

6. Documentation requirements

To support a claim for CPT 99358, the healthcare provider must document the following information:

• The total time spent on indirect patient care activities.
• A detailed description of the activities performed, such as reviewing records, communicating with other professionals, and evaluating the patient’s progress.
• The reason for the prolonged evaluation and management services, including the complexity of the patient’s condition and the need for additional time to manage their care.
• The relationship between the indirect care activities and the patient’s ongoing management or face-to-face care.

7. Billing guidelines

When billing for CPT code 99358, healthcare providers should follow these guidelines:

• Only bill for the first hour of prolonged evaluation and management services, with a minimum of 30 minutes spent on the patient’s indirect care.
• Ensure that the documentation supports the claim, including the time spent, activities performed, and the relationship between the indirect care and the patient’s ongoing management or face-to-face care.
• Use the appropriate modifier, if necessary, to indicate that the service is separate from other evaluation and management services provided on the same day.

8. Historical information

CPT 99358 was added to the Current Procedural Terminology system on January 1, 1994. There have been updates to the code description in 2010 and 2012.

9. Similar codes to CPT 99358

Five similar codes to CPT 99358 and how they differentiate are:

• CPT 99354: Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour. This code is used for direct patient contact in an outpatient setting.
• CPT 99355: Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes. This code is used for additional time spent in direct patient contact in an outpatient setting.
• CPT 99356: Prolonged service in the inpatient or observation setting requiring unit/floor time beyond the usual service; first hour. This code is used for prolonged services in an inpatient or observation setting.
• CPT 99357: Prolonged service in the inpatient or observation setting requiring unit/floor time beyond the usual service; each additional 30 minutes. This code is used for additional time spent in an inpatient or observation setting.
• CPT 99359: Prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes. This code is used for additional time spent on indirect patient care activities beyond the first hour.

10. Examples

1. A physician reviews a patient’s extensive medical records and test results before their first appointment to develop a comprehensive treatment plan.
2. A nurse practitioner communicates with a patient’s previous healthcare provider to obtain additional information about their medical history and treatment progress.
3. A physician assistant evaluates a patient’s response to a new medication and adjusts the treatment plan accordingly, requiring additional time spent on indirect patient care activities.
4. A healthcare provider spends extra time discussing a complex treatment plan with a patient’s family to ensure they understand the risks and benefits of the proposed interventions.
5. A physician reviews the results of a patient’s diagnostic tests and consults with a specialist to determine the most appropriate course of action for their care.
6. A healthcare provider spends additional time reviewing a patient’s progress after a surgical procedure to determine if any adjustments to their postoperative care plan are necessary.
7. A nurse practitioner evaluates a patient’s response to a new treatment regimen and communicates with other members of the healthcare team to coordinate their care.
8. A physician assistant spends extra time reviewing a patient’s medical records to determine if additional diagnostic tests or referrals to specialists are necessary.
9. A healthcare provider spends additional time discussing a patient’s treatment options and potential outcomes with other professionals involved in their care.
10. A physician reviews a patient’s medical records and test results after a significant change in their condition to determine if any adjustments to their treatment plan are necessary.