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.
CPT Code Overview
CPT 99358 is used to report prolonged evaluation and management services that occur without direct patient contact. This code applies when a physician or other qualified health care professional spends additional time on activities such as extensive record review, care coordination, or other non-face-to-face tasks related to ongoing patient management. The service type is prolonged non-face-to-face evaluation and management, and it can be reported in any setting where evaluation and management services are provided, including outpatient offices, inpatient facilities, or observation units. CPT 99358 is specifically used for the first hour of prolonged service on a given date, and it must relate to a patient encounter where face-to-face care has occurred or will occur. This code is not reported for less than 30 minutes of prolonged service.
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
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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 |
|---|---|
207R00000X | Internal Medicine Physician |
208D00000X | General Practice Physician |
207Q00000X | Family Medicine Physician |
Related Diagnoses
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Z71.9: Counseling, unspecified. Used when the physician provides counseling services that require prolonged non-face-to-face time. -
Z76.89: Persons encountering health services in other specified circumstances. Relevant for situations where the patient requires services outside typical clinical encounters, such as administrative or care coordination activities. -
R69: Illness, unspecified. Applied when the patient's condition is not clearly defined, necessitating extensive review and management. -
Z02.89: Encounter for other administrative examinations. Used when the prolonged service relates to administrative or documentation requirements. -
Z00.00: Encounter for general adult medical examination without abnormal findings. Relevant when the prolonged service is associated with routine medical examinations and record review.
Related CPT Codes
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99359: Prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes. Used in conjunction with99358when the non-face-to-face time exceeds one hour. It is reported for each additional 30 minutes beyond the first hour. -
99417: Prolonged time without direct patient contact on the date of office or other outpatient services. Used instead of99358when the prolonged service occurs on the same date as office or other outpatient E/M services. It is an alternative to99358depending on the timing and setting of the service.
99358 and 99359 are commonly used together when the total non-face-to-face time exceeds one hour. 99417 is used as an alternative when the prolonged service occurs on the same date as office or outpatient E/M services.
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: AK1 / 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.
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