CPT 99358 Reimbursement Benchmarks & Policy | OpenPayer

Summary & Overview

CPT 99358: Prolonged Evaluation and Management Service Without Direct Patient Contact

CPT 99358: Prolonged Service Without Direct Patient Contact is a critical billing code for physicians and qualified health care professionals who provide extended evaluation and management services outside of direct patient interactions. This code captures the first hour of non-face-to-face work, such as comprehensive record review, care coordination, and other activities essential to patient management, which are not included in standard evaluation and management codes. Nationally, the use of CPT 99358 reflects the growing recognition of the value of behind-the-scenes clinical work in improving patient outcomes and supporting complex care needs.

The publication covers key payers including Aetna, Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare, providing insights into payer coverage and policy considerations for CPT 99358. Readers will gain an understanding of the clinical context for prolonged non-face-to-face services, typical sites of service, and how this code is used in conjunction with other evaluation and management services. The article also highlights relevant benchmarks and policy updates, helping stakeholders stay informed about evolving reimbursement practices and the importance of documenting non-face-to-face time.

This summary offers a comprehensive overview for clinicians, billing professionals, and policy analysts seeking to understand the role of CPT 99358 in modern healthcare delivery and its impact on reimbursement and patient care.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareCPT 99358prolonged serviceevaluation and management

Clinical & Coding Specifications

Clinical Context

A patient with complex medical needs is seen by a physician for an evaluation and management (E/M) service. After the face-to-face encounter, the physician spends a significant amount of time on a different day reviewing extensive medical records, consulting with other healthcare professionals, and preparing a detailed care plan. This non-face-to-face work is directly related to the ongoing management of the patient's condition and is necessary for high-quality care. The physician documents the total time spent on these activities, which exceeds 30 minutes but is less than 60 minutes, and reports CPT code 99358 for the first hour of prolonged service without direct patient contact.

Coding Specifications

Modifier 25: Used to indicate a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day as another procedure or service.
Modifier 59: Used to indicate a distinct procedural service, signifying that the prolonged service is separate from other services provided.

Taxonomy Code	Specialty

National Reimbursement Benchmarks

For CPT code 99358, national mean rates among commercial payers (BUCA) are notably higher than typical Medicare rates, with BUCA averaging $128.87. Individual commercial payers such as UnitedHealth Group and Cigna report even higher mean rates, at $163.25 and $152.47 respectively. In contrast, Medicare rates are not available in the input for comparison.

Rate dispersion, measured as the difference between the 75th and 25th percentiles, varies across payers. Aetna shows the tightest range at $40.50, while UnitedHealth Group exhibits the widest spread at $86.00. This indicates that reimbursement variability is lowest with Aetna and highest with UnitedHealth Group. The table and chart below present the full breakdown of national benchmarks for CPT code 99358.

State Benchmarks

State: Alaska1 / 50

Alaska Benchmarks

Alaska's reimbursement rates for CPT code 99358 show a substantial spread across payers, with UnitedHealth Group offering the highest mean rate at $280.59 and Aetna the lowest at $171.46. The rate spread, calculated as the difference between the 75th and 25th percentiles, is most pronounced for Cigna ($112.33), indicating significant variability in payment levels. Other payers, such as Blue Cross Blue Shield and BUCA, also display notable spreads, while Aetna's rates are tightly clustered with no spread between percentiles.

Compared to national averages, all Alaska payers provide considerably higher mean rates for CPT 99358. UnitedHealth Group's mean rate in Alaska is over $117 higher than its national average, and even the lowest Alaska mean rate (Aetna) exceeds the national mean by nearly $70. The table and chart below present the full breakdown of payer-specific rates and percentiles for Alaska.

Key Insights for Alaska

UnitedHealth Group is the highest paying payer for CPT 99358 in Alaska, with a mean rate of $280.59.
Aetna is the lowest paying payer, with a mean rate of $171.46.
All Alaska payer mean rates are significantly higher than their respective national averages, with UnitedHealth Group showing the largest deviation.

CPT 99359: Additional Prolonged Non–Face-to-Face E/M Service

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

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National Reimbursement Benchmarks

National Mean Rates for CPT Code `99358` by Payer

State Benchmarks

State: Alaska1 / 50

Alaska Benchmarks

Mean CPT 99358 Reimbursement Rates by Payer in Alaska

Key Insights for Alaska

UnitedHealth Group is the highest paying payer for CPT 99358 in Alaska, with a mean rate of $280.59.
Aetna is the lowest paying payer, with a mean rate of $171.46.
All Alaska payer mean rates are significantly higher than their respective national averages, with UnitedHealth Group showing the largest deviation.

CPT 99359: Additional Prolonged Non–Face-to-Face E/M Service

OpenPayer

Summary & Overview

CPT 99358: Prolonged Evaluation and Management Service Without Direct Patient Contact

Clinical & Coding Specifications

Clinical Context

Coding Specifications

National Reimbursement Benchmarks

State Benchmarks

Alaska Benchmarks

Key Insights for Alaska

Related Codes

CPT Code Overview

Related Diagnoses

Related CPT Codes

National Reimbursement Benchmarks

State Benchmarks

Alaska Benchmarks

Key Insights for Alaska

Related Codes