Electronic consultations

By Alexander Miller, MD, July 1, 2019

Physician-to-physician and patient-to-physician electronic communications have increased recently, and in some cases, have become the norm. Unlike years ago when remote communications were principally facilitated through telephone discussions — today, physicians and patients may communicate through telephone conversations, email, text messaging, and patient portals. Such communications require responses from physicians. Realizing that responses require physician time and work, the Centers for Medicare and Medicaid Services (CMS) has allowed for reimbursement of electronically delivered services, with some qualifiers.

The 2019 Current Procedural Terminology (CPT) offers codes 99446-99449 and 99451 for reporting interprofessional telephone/internet/electronic health record consultations. These codes may be used for reporting services conducted by a consultant at the request of a treating physician or qualified health care professional. The consultant provides services using technology, without direct physician-to-patient or physician-to-physician contact. The consulting physician may offer an opinion about a new or established patient with the consultant. If the consultation is requested for an established patient, the patient should present with a new or worsening problem. The written or verbal request and the reason for the advice from the requesting provider must be documented in the patient’s medical record.

There are restrictions to reporting CPT 99446-99449 and 99451. The patient must not have been seen by the consultant in the preceding 14 days and the consultant must not care for the patient in person within 14 days of the consultation, or when there is a “next available appointment.” Additionally, more than 50% of the electronic communication time must involve verbal or internet discussion rather than records/data review for codes 99446-99449. If the consultation requires more than one telephone/internet/electronic health record contact(s) (e.g., discussion of test results), the entire service and the cumulative discussion and information review time is reported with a single code. The consultation codes are limited to reporting once during a seven-day period.

Code 99451 does not have a greater than 50% discussion time requirement and may be used when the predominant time spent was for records review. Lastly, CPT 99446-99449 require a verbal and written report from the consultant to the consultation requestor. Code 99451 only requires a written report, and no verbal report.

These are the interprofessional consultation codes, revised for 2019:

Δ 99446 Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review

Δ 99447 11-20 minutes of medical consultative discussion and review

Δ 99448 21-30 minutes of medical consultative discussion and review

Δ 99449 31 minutes or more of medical consultative discussion and review

O 99451 Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician, including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 minutes or more of medical consultative time

O 99452 Interprofessional telephone-internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes

CPT code 99452 allows for reporting and billing for work done by the referring physician or qualified health care professional preparing for and/or communicating with the consultant. This includes 16-30 minutes of service time. If the patient is present at the referring professional’s site of service and is accessible to the qualified health care professional, and the electronic discussion with the consultant takes more than 30 minutes beyond the typical time of the appropriate E/M service, prolonged service codes 99354-99357 may be reported. If the patient is not present, then a preparation/discussion lasting more than 30 minutes may be reported with the prolonged service without direct patient contact codes, 99358 and 99359, which are defined below.

99358 Prolonged evaluation and management service before and/or after direct patient care; first hour

+99359 each additional 30 minutes (list separately in addition to code for prolonged service)

Is all the above somewhat confusing? Yes, but it may be useful for reporting legitimate services that take substantial time and effort that were commonly not reimbursable. Presently, your Medicare Administrative Contractor (MAC) will reimburse for the consultation and prolonged services codes when they are reasonable and necessary for covered patient medical care.

Example 1: You provide 15 minutes of an interactive telephone consultation with a referring physician. You generate a written report to the physician, send it electronically, and then schedule the patient, who is new to you, for your first available appointment, which is in one month. You report your consultation with CPT 99447, “11-20 minutes of medical consultative discussion and review.”

Answer: Incorrect. You did the work, and you didn't see the patient in the subsequent 14 days, as stipulated in the code definition. However, you did make an appointment for the patient in a month, and since that was your “next available appointment date of the consultant,” billing for the electronically generated consultation service, which included a written report, is not allowed. If you schedule the patient for your next available appointment, regardless of when it is in the future, the electronic consultation codes may not be reported. What is not clear is whether the service is reportable if the patient declines a next available time and chooses a later appointment date.

Example 2: You spend nine minutes on an electronic health record consultative interchange with a referring physician. The patient was last seen by you for bullous pemphigoid therapy three weeks prior, but as the pemphigoid was flaring and required an adjustment in therapy. You report CPT 99446 for your service after discussing the patient verbally and generating a written consultative report within the electronic health record.

Answer: Correct. Although the consultation involves an established patient with an established diagnosis, the patient’s condition had worsened, thereby justifying both the consultation and the reporting of CPT 99446.

Example 3: You perform an internet physician-to-physician consultation, generate a report, and bill for the service. You recommend that the patient see you for management of the patient’s problem and take over the care of the patient. You bill for the electronic consultation.

Answer: Incorrect. The guidelines stipulate that if a transfer of care’ to the consultant occurs, the consultation codes may not be reported/billed. CMS Medicare Claims Processing Manual, Pub 100-04, Section 30.6.10 states that a physician or qualified non-physician provider consultant may initiate diagnostic services and treatment at the initial consultation service or subsequent visit. However, ongoing management, following the initial consultation service by the consultant physician, shall not be reported with consultation service codes. CMS further defines transfer of care’ as when a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patient’s complete care for the condition and does not expect to continue treating or caring for the patient for that condition.

Example 4: You do a telephone physician-to-physician consultation and three days later, after reviewing pertinent laboratory results, do a second, internet-based consultation. You spend 12 minutes on the initial verbal consultation and 10 minutes on the second consultation, including the time spent reviewing laboratory results. You submit CPT 99448 for your total of 22 minutes of consultation.

Answer: Correct. The CPT instructs that multiple same-patient consultations done during a seven-day period must have their times summed, and only one consultation code should be reported.

Example 5: At the request of a family practice physician you do a telephone and internet consultation on a patient. You recommend a therapeutic intervention for the patient, who remains under the original physician’s care. You generate a verbal and written report then bill an appropriate consultation code to the patient’s MAC. You receive a request for records review from the MAC, which disallows payment for the consultation and demands a refund.

Answer: Correct. You did not document the verbal or written request for an electronic consultation in the patient record. The CPT coding guidelines stipulates that the consultant should document the request and the reason for the request in the patient’s medical record.

Additional DermWorld Resources