How to document extended time spent with patients and families in the nursing home.

How many providers have spent time coordinating care for their patients? Reviewing consult notes, physical therapy orders, care coordination meetings with staff?

All this time spent and no reimbursement for your time. Not only is this frustrating but costs you money because it takes you away from revenue-generating activities.

The good news is there are ways to get reimbursed for your time and energy. It is even easier when the patient has Medicare for their insurance.

The best ways to get reimbursed for your time coordinating care for the resident face to face time and non-face to face time include:

1.      Considering the total time spent coordinating care on the day of the visit in the level of CPT code.

2. CPT code 99358 for time spent on non-face-to-face coordination during the same week as an E&M visit.

All the above will require that you properly document so that you could pass a possible audit. You will need to document the time and what you did that required the additional time.

This code should not be used frequently and only when they meet the requirements of billing per Medicare guidelines.

Using Code 99358 and 99359 in a nursing home for non-face to face time:

 The main thing when utilizing CPT code 99358 is the total time spent over a 24-hour period on non-face-to-face activities. The time includes up to an hour (60 minutes) for this CPT code.

If you are providing care and work for the patient, you can use and document “prolonged evaluation and management service before and/or after direct patient care, the first hour” using CPT Code 99358.

This is a standalone code and should NOT be used the same day as a sick visit. However, you will have to do a recent visit with the same diagnosis codes or plan on doing one soon.

This code is usually used when you need to do an extensive chart review on a patient.

If you use this visit to bill for the non-face-to-face time, then make sure to mention in your note that it is connected to a recent past visit or future E&M visit. It will help if you also document that you spent extended time coordinating care in the E&M visit that you do that is associated.

Example: On Monday, you get a call from a facility that a family member wants to talk to you about the patient’s recent CT scan and to review medications. You call the family and discuss results, make changes to medications, order follow-up labs. The total time is greater than thirty minutes.

You would bill the CPT code 99358 on Monday then do a follow-up visit during the week with the same ICD 10 codes you used on Monday. You would document time in your note (better to use exact times such as 10-10:35 am). You should also show what was done in your note and what are the next steps and who was involved.

After the first hour of prolonged management, you can bill an additional CPT code 9959 for each additional thirty minutes. If you spent an hour and a half, you would bill for a CPT code 99358 and a 99359.

If you are going to bill the CPT code 99359, it must be associated with CPT code 99358. You would bill for these visits just like a normal visit on a different day than the associated E&M visit.

DO NOT INCLUDE OTHER STAFF TIME when billing these CPT codes. It is only for the time that you spent on the patient and family. You cannot use this for “prep time” either. It must be separately identified work that is needed in the care and coordination of the patient.

We currently recommend only using these CPT codes with Medicare patients unless you personally identify commercial insurance payers willing to cover these services.

The great thing about these codes is you can use cumulative time even if not continuous. Think of those days when the nursing home or assisted living facility keeps calling you to manage a sick patient that you will be seeing in the next day or so or have seen recently.

Using Code 99356 and 99357 in a nursing home for prolonged face to face time:

This is a great code for those very time and labor-intensive visits in the nursing home facility. You can use these for the total duration of face-to-face time on the same date of the evaluation of the patient. Remember, your time doesn’t need to be continuous time.

Has there been times when you see a patient in the morning, leave the unit, get multiple calls, then go back to deal with a change of condition or multiple family questions? Then this is the code for you to get paid for your prolonged visit time.

Just remember to document in your note why and what you spent the extra time on in your progress note. Prolonged services involve face-to-face patient contact or psychotherapy services beyond the typical service time.

This is not a code that can be reported more than once per day. You should include non-face-to-face time, such as time spent on the patient’s floor or unit in the nursing facility setting.

CPT code 99358 involves the total time spent over a one-day period (24-hour period) on non-face-to-face activities. This CPT code is up to one hour of total time spent before or after the visit.  Utilize this code when providing care and work for the patient and document “prolonged evaluation and management service before and/or after direct patient care, the first hour”. 

This is a standalone code and should NOT be used the same day as a sick visit. However, you will have to do a medical visit with the same diagnosis codes or plan fairly soon.  

Important note, if you perform other procedures during your exam, do not include this in your additional time.

Occasionally you will need to report time beyond the 1st hour of prolonged time. In this case, you utilize the CPT code 99357. This code is used for an additional thirty-minute block of time beyond the initial hour.

Incorporating time into your level of CPT code

 If you increase the level to a 99310, be prepared to have your note audited. This means getting all the points of a level 99310 in your note. It does not mean writing a book on the patient. If you have an EHR, you could make a template or macro that states >45min with patient/family with >50% of time spent in care coordination and/or counseling. Then adjust the times accordingly.

Some recommend putting actual times In your note such as visit 2:45 pm to 3:30 pm This would include the total time for the visit not just the time in the room with the patient.

Document as much of what you did to help justify the time.

  • Time spent reviewing charts
  • Talking to family and patients
  • Making Appointment or assisting
  • Calling specialists to coordinate care (try to include names)
  • Updating attending physician
  • Discussing plan with family/patient/nurse
  • Other tasks involved in the care of the resident
  • Time spent reviewing charts, medication, reconciliation
  • Brief overview of what was discussed during counseling

Did you spend time coordinating care for your patients? Reviewing consult notes while discussing the coordination of care with the nurse by phone? Sometimes you need to review physical therapy orders and modify plans of care. 

Sometimes you don’t have to be more efficient, sometimes you just document the work you do and bill for the time.

If the visit is long, you can use CPT code 99356: Prolonged physician service in the inpatient setting requiring direct (face-to-face) patient contact beyond the usual service. Remember that this code uses the regular sick visit codes and must exceed the typical time by a minimum of 30 minutes. If a 99309 time is allotted 25 mins, then you could use CPT code 99356 once you exceed the additional 30 mins (55 min mark).

This code allows you to bill for the extra required time. You would use the tips above for documenting the time but would have to be specific with actual times you were working on the patient. Many use this CPT code for new admit evaluations which can be time-intensive.

Document bullet points of what was also done recently by you on recent days such as phone calls, lab reviews, etc. Only document information that is related to the reason for the visit. Remember that the time during the day a non-face-to-face service occurs does not need to be continuous.

Some providers say that they have problems when they combine 99310 with an extended-time CPT code. So maybe best to use 99309 and 99308 CPT or try it out for yourself.

 Disclaimer: The above information is subject to change based on new CPT coding changes based on Medicare, and other insurance payors. This is also not legal, medical, or financial advice and only for educational purposes.


 Are you getting paid for non-face-to-face prolonged care? FPM Journal, 2017. Retrieved November 3, 2021

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