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February 18 , 2008

The Doctor Just Called — Now What?
By Jennifer Swindle, RHIT, CCS-P, CPC-EM-FP, CCP
For The Record
Vol. 20 No. 4 P. 10

There are often medical services provided by physicians outside the normal face-to-face visits that occur in a medical facility. Included among these services is medical communication and management based on telephone calls, which can be done to assess a patient’s status, manage ongoing treatment, confirm medication usage and efficacy, or respond to patient questions.

While these services are necessary for complete and comprehensive patient care, in the past they often were not covered by insurance carriers and separately payable services. Since expected follow-up and some previsit work was frequently included in the evaluation and management code, the telephone services were bundled into the face-to-face services.

Prior to January 1, there was a series of telephone call CPT codes. By description, these codes captured a “telephone call by a physician to a patient or for consultation or medical management with other healthcare professionals to report on tests and/or laboratory results, to clarify or alter previous instructions, to integrate new information from other health professionals into the medical treatment plan, or to adjust therapy.” The correct code series was 99371 to 99373, which differed based on simple, intermediate, or complex services.

This code series was deleted on December 31, 2007, and the individual codes were not assigned any values in the Centers for Medicare & Medicaid Services’ (CMS) relative value unit (RVU) table. They also were not covered by CMS carriers and many commercial carriers. This was often a point of frustration with physicians when significant and contributory work was performed utilizing this means of communication. However, the elimination of these codes is not an indication that telephone calls won’t continue to be a vital component of current medical treatment. In fact, a new code series—99441 to 99443—was created to more clearly identify the correct usage of separately reported telephonic services.

This new code series identifies “telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related evaluation and management service provided within the previous seven days nor leading to an evaluation and management service or procedure within the next 24 hours or soonest available appointment.”

The differentiation between these codes is captured by the amount of time spent providing the service. Code 99441 identifies a five- to 10-minute phone service, 99442 identifies an 11- to 20-minute phone call, and 99443 is used for a 21- to 30-minute phone conversation.

The descriptor change clearly indicates that if the telephone call directly results in an evaluation and management service being scheduled within 24 hours or at the next available urgent appointment, the call should not be reported as it is considered a portion of the preservice work. Likewise, if the telephone call occurs within seven days of a previous evaluation and management service or following an already-reported procedure, it also should not be separately reported as it is considered part of the medical management of the previous evaluation and management service or a normal and integral portion of routine postoperative care.

Additional new codes were also created to capture assessment and management services performed over the phone by qualified nonphysician practitioners. Because different states have different rules regarding the approved scope of care for provider types, local laws and regulations should always be considered and investigated.

The code series 98966 to 98968 was created to accurately capture these services, with the time component delineating the correct code choice. By description, these codes identify a “telephone assessment and management service provided by a qualified nonphysician healthcare professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous seven days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment.”

While any phone communication needs to be documented and supported in the medical record and the work involved in a phone call does take time and effort from the physician, it may still be a service that should be bundled into other evaluation and management services. In that scenario, the documentation will help support medical decision making, and the level of evaluation and management service should be accurately captured. However, with the descriptor changes pertaining to telephone calls, there is not clear guidance, allowing them to be utilized when it is not directly tied to a recent or imminent appointment and potentially be recognized as a separate and reportable medical service.

Because these codes are new and there is not yet data to determine how well they will be recognized and supported by the insurance carriers, an effort has been made to clarify their usage and support a separate service. These codes should be captured and accurately reported to support the medical care handled over the telephone.

While the codes still may not be well received and covered by insurance carriers and may continue to be frustrating to physicians, there is now a way to gather the data and capture all the evaluation and management services provided to the patients. At first glance, the good news appears to be that the CMS has provided work RVUs of 0.25 to 0.75 for these services and included them in the 2008 fee schedule. However, the work RVU and the fee are currently only for reference, and as of January 1, the codes still will not be reimbursed by the CMS.

Another new code was created that recognizes physicians are using different forms of technology to communicate with patients. Code 99444 was implemented to capture medical services and assessments when the communication occurs via the Internet or similar electronic communication. The criteria to meet this code are nearly identical to those surrounding the new telephone call codes with one major difference: The code is not reportable and is considered a separate service if the correspondence originates from an evaluation and management service within the previous seven days. However, the stipulation that it cannot lead to an evaluation and management service or procedure is not included.

To be a reportable service, it must include the physician’s personal time, a response to the patient, and a permanent record of the encounter. However, it should be noted that this code does not currently have a work RVU value and is not payable in accordance with the 2008 CMS fee schedule.

Each year, codes continue to be modified, added, and deleted in an effort to reflect the ever-changing healthcare world and the medical community’s need to report accurate services to all patients. Emerging technologies and patients becoming more active participants in their own healthcare have the potential to expand care and assessments beyond even the telephone and the Internet. As a result, code changes must reflect this changing healthcare landscape.

— Jennifer Swindle, RHIT, CCS-P, CPC-EM-FP, CCP, is a senior consultant of coding services at PivotHealth, LLC in Brentwood, Tenn.