During an initial exam I've determined a functional evaluation test is necessary. I use an independent company to perform the functional evaluation test and a week later I receive the 20 page report. In front of the patient I analyze and discuss the functional evaluation report, sometimes along with other evidence, contemplating the best course of action to treat my patient. I spend at least 30 minutes doing this and bill 99354 (for the 30 plus minute service) and I also would like to bill a 99214 on the same day. Please inform me the best way to bill these two codes together (99214 and 99354) on the same day and what criteria must be met to be compliant for both codes. I would like to confirm 99354 is the correct code for the described work and I also would like to confirm the process; I bill 99214 and then 99354 (after the EM code) on the same day...is a modifier necessary or helpful?

You can bill an E/M code that has a time component (such as 99201-99215, Office or other outpatient visit …To bill a prolonged service you must have documentation for a prolonged service that is more than 30 minutes beyond the typical time listed for the code you billed and have the medical need clearly stated for the prolonged service. Also note that a prolonged time occurs at the time of the preventive annual exam cannot be reported separately.

Is it ever possible to bill 99354 on its own day? The example is, patient came in last week and I billed out 99212 after fulfilling those 99212 requirements. Patient comes back the following week and I would like to bill 99354 after spending 30 plus minutes fulfilling the requirements in the code 99354. On this day I will hope to bill only 99354 as that's the work that I've done on this day. Is this acceptable?

CPT code 99354  is an add-on code. It will always be billed with an E/M code.

I'm a little confused because I asked a similar question regarding code 99358 and this is the answer I received... ...CPT code 99358 represents(Prolonged evaluation and management service before and/or after direct patient care; first hour). Yes CPT code 99358 is an appropriate code to bill for the above service as time spent providing prolonged services performed on a date of service (which may be other than the date of the primary service) that are not continuous. Modifier is not necessary for this case.

PS I realize that 99354 and 99358 are not stand-alone codes and understand differences exist between 99358 and 99354. It has been established in a prior question that 99358 can be billed on its own day (see above) and I was wondering if the same rules apply to 99354 and if not, why?

In case it is confusing let me describe a scenario... Patient comes in today and I bill out 99212 and during this visit I decide a functional evaluation test is necessary. A week later I received the results back aka the functional evaluation 20 page report. The next day this patient comes in and I plan to review and go over the results with the patient, face-to-face, which will take me at least 30 minutes. Can I bill 99354 for this work on this day? If not, please describe how I should handle it. Thank you much for all of your attention and help to this question. I know this question is extensive and I just would like to be clear.

Please note that on the day I go through and discuss the 20-page functional evaluation report (I spend at least 30 minutes) with the patient I do not plan on doing anything else with this patient.

CPT code 99538 represents Prolonged evaluation and management service before and/or after direct patient care; first hour

CPT code 99354 represents Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service)

CPT code 99358 -- This service is to be reported in relation to other physician or other qualified health care professional services, including evaluation and management services at any level. This prolonged service may be reported on a different date than the primary service to which it is related. This code is used to report the total duration of non-face-to-face time spent by a physician or other qualified health care professional on a given date providing prolonged service, even if the time spent by the physician or other qualified health care professional on that date is not continuous. Code 99358 is used to report the first hour of prolonged service on a given date regardless of the place of service. It should be used only once per date.

CPT code 99534 -- Because +99354 is an add–on code, payers will not reimburse you unless you report it with an appropriate primary code such as: 90837, 99201–99215, 99241–99245, 99324–99337, 99341–99350.

The time used to calculate prolonged time on a single date does not need to be continuous.

Regarding 99358...Doctor reviews the functional evaluation report, before he sees the patient on the same day, spending 20 minutes prior to seeing the patient. Then he will see the patient for a regular office visit and also go over the functional evaluation report with the patient which should take at least 10 more minutes. In total for the 99358 we spent 20 minutes non face-to-face and 10 minutes face to face going over the functional evaluation report. Can he bill 99213 or 99214 as an office visit (with a 25 modifier) and 99358 on the same day? And the way we broke up the work for 99358, is that acceptable?

Hi Dave, 

To report cpt 99358, we need to understand what Non-face-to-face time means: This code is purely based on non face to face time.

1. Non-face-to-face time (or pre- and post-encounter time) occurs when the physician performs work related to the patient before or after the face-to-face time or floor/unit time with that patient. It includes tasks such as retrieving records and test results, arranging for further services and communicating with other health care providers and the patient outside of the face-to-face encounter or on the floor/unit. In the hospital, pre- and post-encounter time also includes such tasks as reviewing pathology and radiology findings in another part of the hospital. This is “not included in the time component described in the E/M codes. However, the pre- and post-face-to-face work associated with an encounter was included in calculating the total work of typical services in physician surveys,” according to CPT 2003.

Code 99358 is used for the first 30 minutes to an hour of service, and code 99359 is used for each additional 30 minutes or for the final 15 to 30 minutes on a given day.

 Also please go throught the link provided below.

http://www.aafp.org/fpm/2003/0600/p27.html 

So, in order to be compliant within code 99358, to meet the 30 minutes requirement (for 99358) is it acceptable to spend 20 minutes non face-to-face reviewing the functional evaluation report and then another 10 minutes face-to-face going over the report with the patient? If not, can you provide a better solution?

To be compliant within code 99358, 30 to 74 minutes non face-to-face is required. With just 20 mins non face to face will not allow billing 99358. Secondly, this code is accompanied seeing complex patient i.e higher value E/M codes.

Code 99358 as per CPT guidelines: May be reported on a different date than the primary service to which is it related. Must relate to a service or patient where (face-to-face) patient care has occurred or will occur and relate to ongoing patient management. Does not need to be continuous. Time can not be counted more than once towards the provision 99358 and any other PFS service. Report only once per date of service. Thank you.