*Update: The 2021 OMFS updates drastically changed how E/M codes are billed.*

Among the most important adjustments to the 2017 physician fee schedule was the introduction of CPT Codes 99358 and 99359 as reimbursable codes. For all dates of service on or after March 1, 2017, workers’ comp providers across the state can bill for prolonged non-face-to-face services using the following CPT codes and guidelines:

• 99358 – Prolonged evaluation and management service before and/or after direct patient care; first hour
• 99359 (add-on code; list separately) – Each additional 30 minutes

A new adjustment to the physician fee schedule restricts the amount of time for which these codes may be reported. Effective for all dates of service on or after April 1st, providers will be reimbursed for a maximum of one unit of 99358 and two units of 99359 of non-face-to-face time per patient on any given day. Previously, no limit existed for the amount of non-face-to-face time – and therefore the number of units of 99359 that would be reimbursed per day.

The reason for this new restriction? The quarterly update to the National Correct Coding Initiative Medically Unlikely Edits (MUEs) adopted by the Division of Workers’ Comp (DWC). The newly adopted MUEs now views two-plus hours of prolonged non-face-to-face service as “medically unlikely.”  

So for dates of service on or after April 1st, a provider will only be reimbursed for 2 hours and 14 minutes of non-face-to-face services for one patient on any given day. This effectively caps the prolonged non-face-to-face service reimbursement allowed per day per patient to a maximum of $293.32.

Of course, two hours may not always be enough, “medically unlikely” or not.

The number of units for CPT 99359 is limited by Medicare’s Medically Unlikely Edits (MUEs) as published on the CMS website. An MUE for a HCPCS or CPT Code denotes the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.

Medicare allows exceptions to these MUEs. Providers may report medically reasonable and necessary units of service in excess of the MUE value assigned by Medicare. CPT modifiers such as 76 (repeat procedure by same physician), 77 (repeat procedure by another physician), anatomic modifiers (e.g., RT, LT, F1, F2), 91 (repeat clinical diagnostic laboratory test), and 59 (distinct procedural service) can be used to report additional services units that exceed the MUE value assigned to a service code. Modifier 59 may also be utilized only if no other appropriate modifier describes the service.

If additional time is required beyond the 2 unit limit of 99359, the supporting documentation should clearly explain the reason the number of services reported was medically reasonable and necessary.

Alternatively, providers could obtain authorization for a longer review to be provided on a single day. Remember, authorization guarantees payment.

In the absence of documenting a reasonable explanation or obtaining authorization for a longer review, a provider generally should not report more than two units of 99359, even if they spent longer than two hours and fifteen minutes rendering non-face-to-face services. Doing so would result in a $0 reimbursement for the 99359 line item. (It’s worth noting that units in excess of the medically unlikely edit may be paid through the appeal process. This indicates that it may sometimes be wise to bill extra units, provided the circumstances make for a strong appeal case.)

The time card below shows the maximum time and unit breakdown of codes 99358 and 99359 under the new MUE edit effective for service on or after April 1, 2017.  Remember, reimbursements change annually.

To learn more about reporting these codes, watch our webinar below. While you're there, be sure to download our updated 99358 & 99359 Resource Notebook. It's a detailed guide to reporting these codes, including analysis of CPT guidelines, a supporting document checklist, and a PDF of the time card above.

CPT Codes 99358 & 99359 Webinar