CPT 99359 Reimbursement Benchmarks & Policy | OpenPayer

Summary & Overview

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

CPT code 99359 represents each additional 30 minutes of prolonged non–face-to-face Evaluation and Management (E/M) service provided by healthcare professionals. This code is critical for accurately capturing the extended time spent by providers on activities such as reviewing patient records, coordinating care, and consulting with other clinicians, when these services occur on a date other than the primary E/M encounter and without direct patient contact. The code is typically used in office settings and is billed in addition to the primary prolonged service code.

Major national payers including Aetna, Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare recognize and reimburse for services billed under CPT code 99359. The publication provides an overview of payer coverage, clinical context, and policy updates relevant to this code. Readers will gain insight into benchmarks for utilization, recent changes in billing practices, and the importance of documenting prolonged non–face-to-face services. The analysis also highlights the types of providers who commonly use this code and the clinical scenarios where it is applicable, such as complex case management and coordination of care for patients with chronic conditions.

This summary equips healthcare professionals, billing specialists, and policy analysts with a clear understanding of CPT code 99359, its national relevance, and payer coverage trends.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareCPT 99359prolonged servicenon-face-to-face E/Moffice settingmedical billingpolicy updateclinical documentationprovider taxonomybenchmarkinghealthcare reimbursement

CPT Code Overview

CPT code 99359 is used to report each additional 30 minutes of prolonged service provided on a date other than the face-to-face Evaluation and Management (E/M) service, without direct patient contact. This code is specifically designed for situations where a healthcare provider spends extended time on non–face-to-face E/M activities, such as reviewing records, coordinating care, or consulting with other professionals, beyond the initial hour. The typical site of service for this code is the office setting (Place of Service 11). This code is listed separately in addition to the primary code for prolonged service, reflecting the incremental time spent by the provider.

Clinical & Coding Specifications

Clinical Context

A patient with complex medical needs, such as chronic low back pain, persistent headache, or anxiety disorder, requires extensive care coordination and review of medical records. The physician spends additional time on a day other than the face-to-face evaluation and management visit, reviewing test results, consulting with other healthcare providers, and documenting care plans. This prolonged non–face-to-face service is performed in the office setting and is billed using 99359 for each additional 30 minutes beyond the first hour. The workflow typically involves the physician or qualified healthcare professional dedicating significant time to activities that support patient care but do not involve direct patient contact.

Coding Specifications

Modifier 25: Used to indicate a significant, separately identifiable evaluation and management service performed by the same provider on the same day as another procedure or service.
Modifier 95: Used to denote synchronous telemedicine services rendered via real-time interactive audio and video telecommunications systems.

Provider Taxonomy Code	Specialty Name

National Reimbursement Benchmarks

National mean rates for CPT code 99359 show that UnitedHealth Group has the highest average reimbursement at $78.03, while Aetna is the lowest among the major commercial payers at $42.29. The BUCA average (Blue Cross Blue Shield, UnitedHealth Group, Cigna, Aetna) stands at $59.78. Medicare rates are not available in the input for comparison.

Rate dispersion varies significantly across payers. Aetna exhibits the tightest range between the 25th and 75th percentiles ($20.73), indicating less variability in payment rates. UnitedHealth Group has the widest spread ($40.00), reflecting greater variability in reimbursement. Cigna and Blue Cross Blue Shield also show substantial dispersion, with ranges of $37.00 and $24.63, respectively.

The table and chart below present the full breakdown of national benchmarks for each payer, including mean rates and percentile values.

State Benchmarks

State: Alaska1 / 50

Alaska Benchmarks

Alaska's reimbursement rates for CPT code 99359 show a substantial spread across payers, with UnitedHealth Group offering the highest mean rate at $135.61 and Aetna the lowest at $76.81. The rate spread, measured by the difference between the 75th and 25th percentiles, is most pronounced for Cigna ($51.38), indicating significant variability in payment levels. Other payers, such as Blue Cross Blue Shield and BUCA, display more moderate spreads, while Aetna's rates are tightly clustered at $81.00 for all percentiles.

Compared to national averages, Alaska's mean rates for all payers are considerably higher, with UnitedHealth Group's mean rate nearly doubling its national benchmark. The table and chart below present the full breakdown of payer-specific reimbursement rates for CPT code 99359 in Alaska.

Key Insights for Alaska

UnitedHealth Group is the highest paying payer for CPT 99359 in Alaska, with a mean rate of $135.61.
Aetna is the lowest paying payer in Alaska, with a mean rate of $76.81.
All Alaska payer mean rates are significantly higher than their respective national averages, with UnitedHealth Group showing the largest deviation.

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

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.

National Reimbursement Benchmarks

The table and chart below present the full breakdown of national benchmarks for each payer, including mean rates and percentile values.

National Mean Rates for CPT Code `99359` by Payer

State Benchmarks

State: Alaska1 / 50

Alaska Benchmarks

Mean CPT 99359 Reimbursement Rates by Payer in Alaska

Key Insights for Alaska

UnitedHealth Group is the highest paying payer for CPT 99359 in Alaska, with a mean rate of $135.61.
Aetna is the lowest paying payer in Alaska, with a mean rate of $76.81.
All Alaska payer mean rates are significantly higher than their respective national averages, with UnitedHealth Group showing the largest deviation.

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

OpenPayer

Summary & Overview

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

CPT Code Overview

Clinical & Coding Specifications

Clinical Context

Coding Specifications

National Reimbursement Benchmarks

State Benchmarks

Alaska Benchmarks

Key Insights for Alaska

Related Codes

Related Diagnoses

Related CPT Codes

National Reimbursement Benchmarks

State Benchmarks

Alaska Benchmarks

Key Insights for Alaska

Related Codes