2008 CPT codes clarify billing for phone and electronic E/M

Q: My staff just got their new CPT books. Is there anything in particular that I should notice?

A: Yes, Current Procedural Terminology (CPT) 2008 includes several hundred new codes, some deleted codes and many revisions. As usual, only a few will affect most internists, but there are some notable changes this year.

Because of the number of changes, they'll be addressed in two parts. This month, the column will investigate four new codes for non-face-to-face evaluation and management (E/M) services as well as a minor change in the nursing facility services section. Next month, the column will detail four new codes for behavior change interventions.

Q: I see there are new codes for telephone calls. How are these different from the telephone call codes that were deleted?

A: There are three new codes for telephone services provided by physicians. These codes replace the existing telephone services codes, but have a significantly different description from the codes that were used in the past.

The old telephone services codes were very broad and could be used for all kinds of calls, from physicians to patients, or from physicians to consultants or to other healthcare professionals for coordination of medical management. These codes (99371-99373), which were set up in three levels of complexity, have been deleted from the 2008 CPT book.

The new telephone services codes are more discrete. They are intended to describe phone calls from a patient to a physician during which medical services are provided that do not lead up to or immediately follow another E/M service. The descriptions of the codes are below:

• 99441: Telephone E/M service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; five to 10 minutes of medical discussion
• 99442: 11-20 minutes of medical discussion
• 99443: 21-30 minutes of medical discussion

The new codes essentially replace an E/M visit. In a case in which you might ask a patient to come in for a 10-minute visit or the patient would seek treatment for what is likely to be a relatively minor concern, you instead address the problem on the phone. Because the telephone codes are time-based, it will be important to document the length of the telephone call, in addition to other pertinent information, in the medical record. These codes may only be used for established patients. In addition, the patient must initiate the communication.

There are restrictions on the use of the codes that prevent a physician from using the time involved in the phone calls to count towards billing other codes that include non-face-to-face time, such as care plan oversight. For example, you cannot count your 15-minute phone call as half of the required 30 minutes of time that you need to code for care plan oversight of a nursing home patient in a month.

Q: If a patient calls me on Tuesday and I code for a telephone call, can I also code for a telephone call when the patient calls me on Friday?

A: No. The CPT language indicates that a telephone service may only be billed if another E/M service was not provided within the previous seven days. Since the telephone call codes are themselves considered E/M services, they may not be billed if another telephone call was billed within the last seven days.

Q: I see there is a new code for an online E/M. When do I code for this service?

A: There is a new code for an online medical evaluation. This code had appeared in the past as code 0074T in the back section of the book, which is reserved for Category III codes that represent emerging technology, but is now in the main Category I section of CPT. The description of this service is as follows:

• 99444: Online evaluation and management service provided by a physician to an established patient, guardian, or healthcare provider not originating from a related E/M service provided within the previous seven days, using the Internet or similar electronic communications network

Q: Do I code for this service when I receive the electronic communication from a patient or when I send one back?

A: The asynchronous communication mechanism of online communication presents a new problem in defining the beginning and end of a service. In this case, the service is the entirety of the communication addressing the issue. Note that the entire communication described below would constitute a single service:

• Tuesday morning: patient contacts physician electronically with a complaint
• Tuesday afternoon: physician responds electronically to patient with questions that would lead to a diagnosis
• Wednesday morning: patient answers questions through online communication
• Wednesday afternoon: physician diagnoses patient and recommends a course of treatment

The physician would code for this service on Wednesday. It is important to note that all services must be documented in a medical record in some way. That may be as simple as printing the communication and placing it into a paper chart, or copying it into a medical record.

Q: Do I have to use any particular type of technology to bill for this service?

A: The CPT code does not specify the format of this communication, other than that it use Internet resources. However, a standard e-mail protocol may not meet the requirements of HIPAA privacy standards. The communication used must be private and secure, but physicians are not required to use specific commercial platforms that have been developed for communication between physicians and patients. These commercial platforms, which often have structured questionnaires and interviews, would in many cases meet the requirements of the code, but a less structured option would also meet the standards of the code as long as it is secure. Private payer policies could further dictate exactly what kind of technology would be required.

Q: Is anyone going to pay for this service?

A: The decision to pay for a new CPT code is generally left to individual health insurers. However, online medical services have been enjoying very successful pilots in a number of areas around the country. Telephone services, similar to online services, allow patients to receive the medical advice of their physicians without losing significant time away from work or home responsibilities. The addition of these CPT codes may allow more insurers to recognize and pay for a service that patients are demanding.

Medicare has announced that it will consider the telephone and online services codes to be non-covered services in 2008. Medicare will not pay for the service, however, since the service is considered to be non-covered, it will be possible for physicians to charge patients directly for the service, if appropriate, and be paid cash. Physicians who choose to do this should be careful to note that they are only charging for those services that are described in the codes, which would not include all phone calls. In addition, physicians make sure that they follow all Medicare policies for charging patients for non-covered services.