GOOD NEWS FOR THE VIRTUAL OFFICE VISIT:
HEALTH PLANS ARE BEGINNING TO PAY!
May 2008

Web-based doctor visits are increasing in popularity, and patients and providers alike express appreciation for the convenience of this type of encounter. One major challenge, however, has been payment. While CPT had developed a code for non-face-to-face visits, many plans would not pay for them. Recently, several plans have recognized the value in the service. In fact, since the beginning of 2008, Aetna Inc., the country's largest insurer, and Cigna, have agreed to pay physicians for online visits. Experts expect other large health plans to follow suit.

Online visits typically cost the same as a regular office visit and are aimed primarily at those who already have a doctor (i.e., established patient visits). They are best for follow-up consultations and treatment of minor ailments such as colds and sore throats.

Although face-to-face doctor visits will always be needed, the recent moves are evidence that long-delayed efforts to bring American medicine into the digital age may be gaining momentum, experts say.

"Paying doctors to do more patient care over the Internet is a small but important step in a good direction," said David Cutler, a Harvard University health care economist. "It increases patient access and could significantly improve their satisfaction."¹ Time spent with a physician is a great predictor of patient satisfaction.

Why Offer Online (Virtual) Services?

Offering your patients access to Web-based services is useful for many reasons. While online services may not be face-to-face, they are considered direct patient contact and a great value when patients consider time with their physician. In addition:

1. It has been shown that office visits can be reduced by 25 percent by using online communication with patients. This allows more time with existing appointments, as well as the possibility for a few more open appointment slots.

1. Virtual visits are an opportunity for enhanced payment.

Guidelines for Non Face-to-Face Services:

The 2008 edition of CPT established codes for online Evaluation and Management (E/M) services provided by both physician and non-physician providers. Along with these codes came guidelines for provision of the service and use of the code(s):

• Service provided by a physician or non-physician to the patient at the request of the patient or guardian of patient;

• Patient is required to be an established patient;

• Not to be reported if the non face-to-face service ends with a decision to see the patient within 24 hours or at a next available urgent visit appointment;

• Not to be reported if non face-to-face service refers to an assessment and management service performed and reported by the physician or non-physician within the previous seven days or within the postoperative period of a previously completed service; and,

• Not to be reported if another telephone or online E/M service has been reported in the previous seven days.

Coding for Online Visits:

The codes to be used for online E/M services are:

• 99444   Online assessment and evaluation by a physician to an established patient, guardian, or health care provider not originating from a related E/M service provided within the previous seven days, using the Internet or similar electronic communication network.

• 98969   Online assessment and service provided by a qualified non-physician health care professional to an established patient, guardian, or health care provider not originating from a related assessment and management service provided within the previous seven days, using the Internet or similar electronic communications network.

Note:    The CPT code description implies that this service could be used to communicate with another health care provider about a patient, but there is no evidence at this time to indicate that an insurer would pay for this service.

Documenting an Online Visit:

Feedback from patients who have used online services is overwhelmingly positive. Most online consultations are far more structured than a simple e-mail. If insurance companies are expected to pay the bill, physicians need documentation of the event, including diagnosis and (some say) time spent.

Examples:        

CPT 99444        An established patient, traveling out of town on business, e-mails her physician for the onset of fever, cough and other cold-type symptoms. In the subsequent e-mail exchange, the physician reviews the interval history, diagnosed a bacterial infection, prescribed an antibiotic from a drugstore near the patient, suggested rest and recommended the patient contact him again in 10 days if not better. No office visit is required at this time. The e-mail communication is kept as part of the patient's medical record.

CPT 98969        A 51-year-old male sends an e-mail message to the PA two weeks after an office visit with the PA for new onset of shoulder pain, during which an x-ray was normal and the PA advised conservative measures. In the e-mail, the patient notes no improvement of his symptoms. In the subsequent e-mail exchange, the PA reviews the interval history, advises a change in anti-inflammatory medications, initiates a set of mobilization exercises using education materials and a Web-based video, and recommends that the patient contact him again in two weeks for possible MRI and physical therapy referral if not improved. No office visit is required.

When documenting these services, the entire event should be included, remembering that it is an established E/M service. Therefore, two of the three key components of an E/M service (e.g., history, exam, medical decision making) should be recorded.

Payment for Online Services:

Non-payment by most health plans has been a major roadblock for expansion of the virtual office. Since some of the major insurers are now covering the service, however, it is expected that more will follow. Unfortunately, some smaller insurers that began paying for online consultations recently stopped doing so because few members used the service.

Pricing for the service varies, but should typically equate to your fee for a 99212 or 99213. When determining your fee, you want the fee to reflect the fact that you may have two or three related e-mails to complete the "visit", but you'll be billing it all as one service.

Just as fees vary, so does payment. Aetna and Cigna payment range from $26 to $32, depending upon geographic areas and individual contracts. Some pilot projects with Kaiser Permanente have reimbursed as high as $50/visit.

The Medicare program is still on the sidelines when it comes to payment. It is considered a non-covered item, however, as opposed to a bundled service, so Medicare beneficiaries can be billed directly for this service. The same is true of Blue Shield of California. Anthem (Blue Cross of California) submits the service for medical review and then typically denies it for medical necessity, but if the patient has signed a waiver prior to participating in the service, you may be allowed to bill the patient directly.

Getting the Word Out:

If your practice offers online consultations/services, your patients need to know it! A few ways to get the word out include:

• Announcement in monthly billing statements
• Announcement on practice Web site
• Article in practice newsletter
• Mass mailing to targeted patient base
  • Give instructions for use
    • What is appropriate for e-mail
    • What conditions or requests should not be addressed by e-mail
    • Who can use (ESTABLISHED patients only - those who have been seen within a given period of time)
    • The expected wait time for a response
    • Whether or not you are using a secure e-mail system
  • Give instructions for sign up (if needed)
  • Give instructions for accessing
• Recording on practice communication (telephone) system

Summary

Providing access for a virtual visit is a concept every family physician should consider. It satisfies the patients' thirst for timely access to care and allows them to conveniently communicate with you - whether from home or work, regardless of the time of day. This type of information exchange allows them to describe their problem and formulate their questions without feeling rushed. And because they have your response in writing, they can reread the information as often as they like or need to understand the content.

This is a valuable service than can be offered to patients. But, don't give it away - it is an add-on service that should be priced appropriately and billed to either insurance or the patient.

For more information on e-visits access:

"Not Billing for these Services Can Cost Your Practice Revenue," CAFP's Practice Management News, November 2007 http://www.familydocs.org/

AAFP Family Practice Management, October 2007; www.aapf.org/fpm

Information Week, May 31, 2004; http://www.informationweek.com/

¹ David Cutler, Harvard University Healthcare Economist; LA Times; February 4, 2008

Mary Jean Sage is a coding and practice management consultant in Pismo Beach, CA. She can be reached at maryjean@thesageassociates.com.

Side Bar

California is Getting a New MAC (Medicare Administrative Contractor)

Effective September 2, 2008 (subject to change if necessary) California will have a new contractor (carrier). Palmetto GBA was awarded the contract to be the Jurisdiction 1 (J1) Medicare Parts A/B MAC. Jurisdiction 1 includes California, Nevada, Hawaii, the territories of American Samoa and Guam, and the Northern Mariana Islands. A smooth transition is planned with no anticipated disruption in administration of the Medicare enrollment, claims adjudication or appeals processes.

At this time there are two things you should know:

1. All providers will need to submit a new EFT (Electronic Funds Transfer) application authorizing Palmetto GBA to initiate credit entries into your bank account - the request for that application has gone out to all effected physicians and should be returned by 8/18/08 to assure no disruption in receiving Medicare payments to your practice bank account.

1. All providers who submit claims electronically will need to sign a new EDI agreement with Palmetto GBA. These requests have also gone out. Watch your mail and make sure the agreements are returned in a timely manner to assure to no disruption in your claims submission process.

1. The process of consolidating Local Coverage Determination policies has begun. To keep in tune with this process access: www.palmettogba.com/J1