- 99358 (Prolonged evaluation and management service before and/or after direct patient care; first hour); and
- 99359 (Prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes [List separately in addition to code for prolonged service]).
The two codes are intended to reimburse providers for work conducted outside of an office visit, an area that CMS has said previously it wanted to bring in line with its greater fee-for-service model.
"We agree that these codes would provide a means to recognize the additional resource costs of physicians and other practitioners when they spend an extraordinary amount of time outside the in-person office visit caring for the individual needs of their patients," states the proposed rule.
The proposed rate for 99358 is $113, and $54 for add-on code 99359, according to estimates. But don't start calculating your receivables yet.
A billing rule associated with the proposed codes may result in underuse of the services, notes Valerie Rock, CHC, CPC, manager with health care business consultancy PYA in Atlanta.
As currently proposed, a billing requirement stipulates that providers will be required to perform the prolonged service code on the same date as a "companion E/M code," according to the proposed rule. CMS says, "we propose to require the services to be furnished on the same day by the same physician or other billing practitioner as the companion E/M code."
The single-day restriction runs counter to current CPT guidance, says Rock. "CPT states as of 2012 that these codes do not have to be billed during a single day," she says, citing CPT Assistant, August 2012.
Those who feel the single-day restriction will limit the effectiveness of the codes should share their concerns with CMS, advises Rock. The
public comment period is open through Sept. 6 at 5 p.m. (EST).
To date, several comments address the proposed prolonged-service codes.
One commenter states: "While I thank CMS for proposing to recognize CPT codes 99538 and 99359 for CY 2017, I urge CMS to revise this proposal and not require these services to be furnished on the same day by the same physician."
Wider latitude may help providers meet the goals of value-based care, says Rock. "Paying physicians and staff for the actual time they spend in these services will allow physicians to spend time in the area of care coordination as CMS intends for the future to increase the effectiveness of health care," she says.