Prolonged Services without Direct Patient Contact Codes (99358-99359)

Codes for prolonged services without face-to-face time are used when the physician reviews extensive records, and/or tests or communicates with other professionals and/or the patient/family before and/ or after the face-to-face encounter. The non-face to-face prolonged services codes may be reported on a different date than the primary service to which it is related. The services may be for extensive record review, and may be related to an E/M service performed earlier; service commences on receipt of past records. The service must be directly related to the face-to-face encounter with the patient and the encounter must have occurred or will occur.

Prolonged services lasting <30 minutes are included in the basic E/M services for the patient. Many third-party payers will not reimburse for prolonged services without a face-to-face visit with the patient. An example of a prolonged services situation would be a patient who has already seen the physician for a detailed history, detailed exam and moderate medical decision-making (99214). Then the patient requests a conference beyond the encounter, and this conference lasts an additional 35 minutes. The appropriate coding would be for a 99214 and a 99354. It is not appropriate to code for prolonged services and for an allergy test during the same period of time for which the allergy testing is being performed. This would be interpreted as “double-dipping” in the time component. Documentation of total time spent with the patient is required to support the coding of E/M plus prolonged services.

Pulmonary Codes

Pulmonary Function Codes. Most diagnostic codes have a professional and a technical component. Pulmonary function codes have a professional component (26 modifier), which is the interpretation of the results of the technical component. If the equipment is owned by the same group that does the interpretation, then the code (94010) is not divided into two components. The term for this code is called the global code. The entire five-digit code, without any modifiers, is charged for the services provided to the patient. If the technical component is owned by one entity (such as a hospital) and the physician works as a separate entity, then the code would be billed by appropriate component of the global code using the correct modifier (i.e., 26 or TC [technical component]). 

Because pulmonary function codes are considered diagnostic studies, many of these services are provided by the ancillary staff under the supervision of the physician. According to the CMS, there are three types of supervision for the technical component of the diagnostic testing. Section 410.32(b) of the Code of Federal Regulations requires that, with certain exceptions, diagnostic tests covered under 1861(s)(3) of the Social Security Act and payable under the physician fee schedule have to be performed under the supervision of an individual meeting the definition of a physician. When non-physician providers supervise diagnostic testing for Medicare patients or other patients whose insurance coverage follows the CMS “incident to” guidelines, the diagnostic testing would be charged under the non-physician’s provider number. The allergy practice should check their third-party payer contracts to verify how non-physicians are to bill for their services. The definitions of the supervision guidelines are as follows:

• General supervision. The physician does not need to be on site when the services are performed. The staff may perform the services without the physician present. There must be a physician order for the diagnostic procedure. An example of this situation is simple spirometry (94010). 

• Direct supervision. The physician must be in the office suite when the diagnostic service is performed but does not need to be face-toface with the patient. The physician must be immediately available to provide assistance and direction for the pulmonary service. An example is spirometry, before and after bronchodilation (94060).

 • Personal supervision. The physician must be with the patient while the diagnostic pulmonary function study is being performed. An example is the methacholine challenge (94070 and 95070).

Most pulmonary function studies require direct supervision when service is to be performed by nursing staff. Basic spirometry is the only general supervision situation. This information is available on the Physician Fee Schedule RVU for each calendar year.