COMMENTARY

Getting Paid for Helping Other Doctors; Reimbursement for Time Spent Before and After Seeing a Patient

Betsy Nicoletti, MS

Disclosures

October 20, 2020

Betsy Nicoletti, MS, a nationally recognized coding expert, will take your coding questions via email and provide guidance on how to code properly to maximize reimbursement. Have a question about coding? Send it here.

In this column, Nicoletti addresses how to code for physicians consulting other physicians and how to properly account for time spent before and after a patient visit.

Coding for Consulting With Other Physicians

Q: I am interested in the "doctor-to-doctor" consult model of care. However, I know very little about coding and reimbursement in this situation. I am an endocrinologist and saw some information online from a fellow practitioner who claims that Medicare and Medicaid both reimburse for these services. Can you give me some details? Do both the referring physician and the consultant use Current Procedural Terminology (CPT) codes? What about private payers?

A: There are CPT codes for interprofessional consults, which were recognized by Medicare in 2017. As active CPT codes, most payers should recognize and reimburse for them. These visits do not require an in-person visit.

Five of the codes (99446-99449 and 99451) are for use by a consulting physician who does a phone, internet, or electronic record review and provides a written report to the requesting clinician (Table 1). CPT describes these codes as the work of a physician and does not include the words "other qualified healthcare professional" in the description.

There is a sixth code (99452) for use by the treating physician or other qualified healthcare professional who asks for the referral, which covers the work of providing the information to the consulting physician (Table 1). All of these are time-based codes. The time spent in performing the consultation must be documented.

Patient consent is required before the consulting physician's visit or consultation. Because the consulting physician is not seeing the patient, the requesting clinician must obtain and document consent for the service, so that the patient knows there will be a bill for the consultation. This consent may be verbal or in writing, but it must be documented in the medical record.

The service may be performed for a new or established patient, and for a new or existing problem. The consultant may not have had an in-person visit with the patient in the past 14 days, and it may not lead to an in-person visit within the next 14 days. A physician may not report these codes more than once in a 7-day period. The services should not be used for a hand-off, when care is being transferred to the consulting physician. Codes 99446-99449 may not be billed if more than 50% of the time is spent in data review.

Table 1. CPT Codes for Consulting With Other Physicians

CPT code

Description

2020 wRVU

National facility and nonfacility payment

99446

Interprofessional telephone/internet/electronic health 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 healthcare professional; 5-10 minutes of medical consultative discussion and review

0.35

$18.41

99447

11-20 minutes of medical consultative discussion and review

0.70

$37.17

99448

21-30 minutes of medical consultative discussion and review

1.05

$55.58

99449

31 minutes or more of medical consultative discussion and review

1.4

$73.98

99451

Interprofessional telephone/internet/electronic health assessment and management service provided by a consultative physician, including a written report to the patient's treating/requesting physician or other qualified healthcare professional, 5 minutes of medical consultative discussion and review

0.70

$37.53

99452

Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified healthcare professional, 30 minutes

0.70

$37.53

wRVU = work relative value unit

If more than 50% of the time is spent in data review, the physician is limited to code 99451 (Table 1).

For the treating physician, there is only one code and it requires 16-30 minutes of time in a day, preparing for the internet referral and communicating with the consulting physician. Code 99452 may be performed by a physician, nurse practitioner, or physician assistant. It is valued at a lower level than the consulting codes (Table 1). It has the same RVUs and payment as code. However, code 99451 requires only 5 minutes of time.

There was added interest in these codes at the start of the pandemic as a way to limit the number of healthcare professionals who visit infected or potentially infected patients. But the codes are not limited to use during the pandemic. One barrier to reporting them is obtaining and documenting the patient's consent for a consult that isn't an in-person service.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....