A cancer patient who has had a relapse after moving states is an inpatient at the cancer floor of the local hospital. Her current oncologist has obtained her previous medical records from oncology, pulmonology, general surgery, transplant team, and cardiology and is spending a significant amount of time reviewing her previous care and how the cancer was treated by her previous doctors. He has spent an additional hour going over the charts from her previous providers and has spent time on the phone with her previous oncologist. This prolonged service did not involve face-to-face time with the patient but was necessary for review of her medical history and previous treatments and responses. What evaluation and management code should be used for this encounter?

Question

Quizplus · Accepted Answer

99358 is the correct code for prolonged service without direct patient care. This physician spent 60 minutes going through her previous records and talking with her previous oncologist to provide the best care he can for this patient.
Codes 99356 and 99357 are codes used for prolonged direct patient care contact in the inpatient or observation setting. Code 99359 is the "add-on" code for prolonged service without direct patient contact over the first 60 minutes. If this physician had provided 30 more minutes of care over the first 60, then this code would be used in addition to 99358.

A Cancer Patient Who Has Had a Relapse After Moving