99358

Prolonged Evaluation and Management Service Before and/or After Direct Patient Care; First Hour

CPT code 99358 is utilized to report the first hour of prolonged evaluation and management (E/M) services provided by a physician or other qualified healthcare professional that do not involve direct, face-to-face patient contact. These services occur on a separate date from any face-to-face E/M encounter. The clinical utility of 99358 lies in recognizing the extensive cognitive work involved in managing complex patients, which often happens outside the exam room. This work includes, but is not limited to, the exhaustive review of extensive medical records, including hospital discharge summaries, specialist consultation notes, and historical diagnostic imaging or laboratory results. It also encompasses the time spent synthesizing this information to form a cohesive management plan, communicating with other healthcare providers involved in the patient's care, and discussing treatment options with family members or caregivers when the patient is not present. From a procedural standpoint, 99358 is a time-based code. To report the first hour, the provider must spend at least 31 minutes of non-face-to-face time on a single date. If the service is less than 31 minutes, it is generally considered part of the pre- or post-work of the associated E/M visit and is not separately reportable. This code is particularly relevant in specialties such as oncology, neurology, and complex pediatrics, where patients often have thick medical files and require coordinated care across multiple systems. Unlike the same-day prolonged service codes, 99358 allows for reimbursement of the intensive desk work that is vital for quality care but often goes uncompensated. Documentation must clearly identify the patient, the specific activities performed (e.g., reviewing 50 pages of records from an external cardiology clinic), and the exact duration of the service to meet payer requirements for medical necessity. This ensures that the physician's time spent on critical thinking and care coordination is accurately captured and billed.

Clinical Indications

  • Review of extensive past medical records from multiple outside facilities for a new complex patient.
  • Care coordination with multiple specialists on a day when no face-to-face visit occurs.
  • Extensive review of genomic or complex diagnostic testing results to adjust treatment plans.
  • Management of complex chronic conditions requiring significant data synthesis and longitudinal planning.
  • Preparation for or follow-up from a complicated hospital discharge or transition of care.
  • Review of patient-reported data and home monitoring logs that exceed the scope of a standard visit.

Procedure Steps

  1. Identify the clinical necessity for extensive non-face-to-face evaluation related to the patient's management.
  2. Ensure the non-face-to-face work is performed on a date separate from the face-to-face E/M encounter.
  3. Conduct a thorough review of medical records, diagnostic reports, or other relevant patient data.
  4. Coordinate care via communication with other healthcare professionals or relevant non-clinical stakeholders.
  5. Record the start and stop times or the total cumulative duration of the non-face-to-face activity.
  6. Document the specific nature of the activities performed and how they contribute to the patient's care plan.

Coding Guidelines

  • Use 99358 to report the first 31-60 minutes of non-face-to-face prolonged service on a given date.
  • Report 99359 as an add-on code for each additional 30 minutes of service beyond the first hour.
  • Do not report 99358 or 99359 for services provided on the same day as a face-to-face E/M visit (use 99417 instead).
  • A minimum of 31 minutes must be documented to report 99358.
  • These codes are for the use of physicians or other qualified healthcare professionals, not clinical staff.
  • Do not report 99358/99359 if the work is already captured by Care Management or Transitional Care Management codes.
  • Ensure documentation explicitly states the total time spent to justify the service.
  • Note that for CPT office visits, 99213 requires Low MDM (20-29 mins) and 99214 requires Moderate MDM (30-39 mins); 99358 is distinct from these visit times.

Associated ICD-10 Codes