Interprofessional Consultants & Alternative Delivery Methods for Care
by Diane E. Zucker, M.Ed., CCS-P
Health Care Management Consultant
CMS has changed the way health care is considered and paid not only by Medicare but many commercial insurance plans. Part of this change is the mandated requirement for Medicaid to cover many of these services as part of the standardization in health care delivery and reimbursement. More and more health care is provided in non- traditional ways. With the public health emergency telehealth and telephone services became accepted. With the increase of EMR medical records there is now coding for digital evaluations. There are also codes for care provided without direct patient involvement. These changes include the Interprofessional consultations between health care providers. The following is a summary of these new methods of care delivery.
The Basic Telehealth Services
Telehealth is when you provide audio and video communication with a patient through a secure internet process (not just face time). This audio and video visit is coded with the E/M CPT codes (99202-99215) based on the complexity of care provided or total time for the date of service in clinical care activities The patient care must be provided with informed consent of the risks and benefits of telehealth services, understand that there may be co-payments and/or co-insurance and that you the provider may require that they come in in person for care based on your clinical judgement. The documentation would include all the aspects of care, as if the patient was in the same room as you. Based on specialty and condition of the patient, telehealth may have limited use.
The element of the exam varies in importance for specific patient encounters and specifics specialties. In primary care the history may drive the initial or follow up care more than with ENT or Orthopedics. In some cases, the prior history and exam available to the provider may support and help in the care process, in others there is a need for hands on exam to determine the work up, plan of care and risk. Follow up care may be amenable to telehealth with review and discussion about the diagnoses or treatment options, response to treatment, discussion about referrals
Medicare, Medicaid, and most insurance plans pay for telehealth with the identified CPT code and modifier GT.
The Telephone Calls
Telephone calls are coded with the 99441 through 99443 series of codes that are time based and used for established patient alone. The full definition includes: Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment. The 99441 is for 5-10 minutes, the 99442 for 11-20 minutes and the 99443 is for 21-30 minutes.
These types of calls are not just simple prescription refill but would involve some information exchange, information and a component of care that requires a medical provider to discuss the issue and care with the patient. An example might be discussion of test results with a patient that require intervention or additional testing or a discussion prior to surgery upon review f medical history that necessitates a change in the surgical care plan.
These services are payable by Medicare, Medicaid and most commercial insurance plans, no modifier is required.
Online Digital Evaluation
These services are coded with the 99421-99423 series of codes with the following definition: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days and identified further Online medical evaluation services are non-face-to-face encounters originating from the established patient to the physician or other qualified health care professional for evaluation or management of a problem utilizing internet resources. The service includes all communication, prescription, and laboratory orders with permanent storage in the patient's medical record. The service may include more than one provider responding to the same patient and is only reportable once during seven days for the same encounter. Do not report these codes if the online patient request is related to an E/M service that occurred within the previous seven days or within the global period following a procedure. Report 99421 if the cumulative time during the seven-day period is five to 10 minutes; 99422 for 11 to 20 minutes; and 99423 for 21 or more minutes.
This may be the patient that you are communicating with via the internet, review documentation, making orders or referrals and answering questions, clarifying a treatment plan providing them educational information about their condition and perhaps getting feedback on their response to care, treatment and/or medication.
These services are payable by Medicare and Medicaid, and covered by commercial insurance plans based on your contracting with them.
Prolonged Non-Face-to-Face Care
The 99358 and 99359 are Prolonged evaluation and management care that maybe provided before or after a patient encounter. The full definition of this service is : Prolonged time without direct contact with the patient that is performed by the physician or other qualified clinician on a different day than a related E/M service can be reported with 99358 and 99359. For example, the provider may review records for a patient who received a face-to-face E/M service on a previous date or will receive care on a future date. The reported E/M service does not have to be selected based on time to report these prolonged timed services. Time reported for prolonged care should be for the total duration of time spent by the provider even when the time spent on that date is not continuous. Report 99358 for the first hour of prolonged care without direct patient care that is performed on a different date than the face-to-face E/M service and 99359 for each additional 30 minutes. The 99358 cannot be reported until at least 31 minutes of activity has been provided.
These services are covered by Medicare but are not yet in the Medicaid fee scheduled as of 3/1/2023.
The Interprofessional Consultant Services
These services are coded with the 99446 through 99449 and 99451- 99452. These services are for the consulting provider to assess and determine a diagnoses, treatment plan or options for an identified patients. CMS requires that Medicaid plans cover these services, however as of 3/1/2023 they are not in the Ohio Medicaid fee schedule. They are covered by Medicare and many commercial contracts. The definition of the care is as follows:
The 99446 through 99449 Interprofessional telephone/internet/electronic health record consultation services are utilized when the attending qualified clinician requests the input of a physician or qualified clinician with specific knowledge of the condition. This specialist may assist in diagnosis or treatment of the patient without seeing the patient and often occurs when the situation is urgent and/or complex in nature. The patient may be a new or established patient with a new problem or exacerbation of a current problem in the eyes of the consultant; however, the consultant may not have seen the patient within the previous 14 days. This code may not be reported for transfer of care or to schedule a face-to-face with the consultant within the next 14 days or next available appointment opening. This discussion includes appropriate review of medical records, laboratory and radiology results, medication review/tolerance, and pathology results. The consult should account for more than 50 percent of the time in discussion; if more than one discussion is necessary, the time is cumulative with the code reported one time. The patient's medical record should contain a request for consultation with an explanation as to the medical necessity of the request and the consultant should provide a verbal and written report to the requesting/treating clinician. These codes are not reportable if the discussion requires less than five minutes of time.
Report 99446 for encounters of five to 10 minutes; 99447 for encounters 5 to 10 minutes; 99447 for encounters 11 to 20 minutes; 99448 for encounters 21 to 30 minutes; 99449 for encounters more than 30 minutes.
An example in ophthalmology may be a retina specialist who is reviewing prior care, images and testing to determine the appropriate plan for a patient or a pediatric ophthalmologist assessing a unique issue or concern that requires a complex care plan.
The 99451 and 99452 Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician or other qualified health care professional, including a written report to the patient's treating/requesting physician or other qualified health care professional; Report 99451 for encounters of five or more minutes that include a written report only from the consultant. The attending qualified clinician can report 99452 when 16 to 30 minutes of the clinician's time is spent preparing for or communicating with the consultant; 99452 can only be reported once during a 14-day period.
Review of pertinent medical records, laboratory studies, imaging studies, medication profile, pathology specimens, etc. is included in the telephone/Internet/electronic health record consultation service and should not be reported separately when reporting 99446, 99447, 99448, 99449, 99451. The majority of the service time reported (greater than 50%) must be devoted to the medical consultative verbal or Internet discussion. If greater than 50% of the time for the service is devoted to data review and/or analysis, 99446, 99447, 99448, 99449 should not be reported. However, the service time for 99451 is based on total review and interprofessional-communication time.
The written or verbal request for telephone/Internet/electronic health record advice by the treating/requesting physician or other qualified health care professional should be documented in the patient’s medical record, including the reason for the request. Codes 99446, 99447, 99448, 99449 conclude with a verbal opinion report and written report from the consultant to the treating/requesting physician or other qualified health care professional. Code 99451 concludes with only a written report.
The documentation in these cases would need to identify the referral source, the time involved in the activities for assessment, remembering the limited data time for codes 99446-99449, and the response to the referring provider. One also needs to make sure that the patient is aware of this referral and activity prior to the encounter as they may be responsible for co-payments or amounts assigned to a deductible. For Medicaid these services will be covered as of 4/1/2023 with the policy following the AMA CPT coding process.
In 2023, there are a number of coding options, beyond the face-to-face visit codes that an all physicians and qualified health care professionals could provide to their patients to enhance the quality of care and in some cases provide the care in a more efficient way. As you think about these methods of care delivery remember that informed consent is critical for telehealth, phone calls and digital assessments with patients. For the consultation services the referring physician or other qualified health care professional should notify the patient of your role in care. In providing these types of care one should also make sure they are part of your billing and compliance process as well as part of your contracting with commercial insurance plans.