Getting paid for online digital E/M services

Editor's note: this post was updated Aug. 28, 2023, with examples of reportable and non-reportable online digital E/M services.

Overall, utilization and payment for telemedicine visits increased significantly during the COVID-19 public health emergency and has largely continued. The increased use of telehealth not only includes telephone and video visits (for which billing is relatively straightforward) but also includes patient messaging to physicians for health care advice and remote E/M services (for which billing may be less clear).

Family physicians may be feeling the burden of uncompensated time spent reviewing and responding to patient portal messages, as noted in the recent FPM article “Using a Nurse Triage Model to Address Patient Messages.” While some services — like providing a patient with results of testing ordered at a recent visit — are included in the work of the visit, other services are separately reportable. Distinguishing billable services is the key to making the most of time spent reviewing and responding to patient messages.

First, it is important to understand what is not separately reportable per CPT guidelines:

• Nonevaluative electronic communication of test results, scheduling of appointments or billing questions, or other communication that does not include E/M,
• Any online digital E/M service that is followed by an in-person or telemedicine visit within the next seven days,
• An online E/M service for the same or a related problem within seven days of a previous E/M service.

It is important to recognize that the relative value units (RVUs) assigned to each E/M service include a specific amount of pre- and post-service work that is not separately reportable. The post-service time is described by the AMA/RUC as being within seven days following the office visit and includes answering follow-up questions from the patient and/or family and responding to treatment failures or complications, or adverse reactions to medications that may occur. The total RVUs are the basis for payment whether this amount of post-service work occurs or does not. One service may require more post-service work where another may require none.

So, when are online digital E/M services separately reported? Report codes 99421-99423 for an "online digital E/M service" when all of the following are true of the service:

1. The service is patient-initiated,
2. The patient is established,
3. The service requires a physician’s or other qualified health care professional’s medical decision-making,
4. The service is unrelated to an E/M service that occurred in the prior seven days (i.e., it is for an unrelated problem),
5. No face-to-face or telemedicine visit occurs within the seven days after the online E/M service is provided.

Codes 99421-99423 are time-based codes that include the documented cumulative time devoted to the service during a seven-day period:

• 99421    5-10 minutes,
• 99422    11-20 minutes,
• 99423    21 or more minutes.

See your CPT reference for a detailed description of activities included in the time of service.

Another option for reporting work related to a patient’s request for online digital E/M is Medicare’s coverage of brief check-ins to decide whether an office visit is required or not. See a comparison of virtual check-in codes G2012 and G2010 and other virtual visits in AAFP’s “How to Code for Telehealth, Audio-Only, and Virtual-Digital Visits.”

Here are two examples of reportable online digital E/M services:

1. An established patient who has not received an E/M service in the last seven days sends a message through his physician’s patient portal requesting an online digital E/M service for advice on managing seasonal allergies. The patient agrees to the practice’s terms of service and electronic access to the practice’s HIPAA notice. The patient then enters a brief history of the present illness and any current medications or other actions taken to relieve symptoms. The physician reviews the patient’s request and history and uses the same messaging system to recommend an over-the-counter allergy medication and eye drops to relieve symptoms. The physician’s total time reviewing the patient’s request and history and responding is 10 minutes. If the physician spends any additional time in follow-up to this visit via the patient portal within the next seven days, the practice adds that time to the initial 10 minutes and selects a code based on the cumulative time over the seven-day period. All communications, orders, and notes related to the encounter are electronically stored and accessible as needed. (When a face-to-face E/M service is provided within seven days after the online E/M service, only the face-to-face service is reported.)
2. A patient who received an office E/M service from a family physician five days ago for follow-up of diabetes and hypertension uses the family physician’s portal to request an online digital E/M service to evaluate a skin lesion. The patient includes digital images of the lesion. The physician reviews the images and patient’s history and responds that it appears to be a common benign lesion but offers to evaluate it in person either now or at the next scheduled visit. The patient is reassured and agrees to reevaluation at the next in-person visit in three months. The physician’s time devoted to the service is 15 minutes. No further services are rendered within the seven-day period and the physician reports code 99422. The service is separately reportable because, though it occurred within seven days of a previous visit, the reason for the online E/M was unrelated to the reason for the prior visit.

Here are five examples of online digital services that are not separately reported:

1. A patient received an online digital E/M service reportable with code 99422 that resulted in an office visit within the next seven days. When the patient receives the office visit service, only the code for that service is reported. Code 99422 cannot be separately reported.
2. A parent of a child who was seen in the office three days ago for an ear infection requests an online E/M service regarding the child’s upset stomach and mild diarrhea since starting medication. A physician of the same specialty and same group practice as the physician who saw the patient three days ago reviews the request and responds with advice for managing the patient’s symptoms. The service is not separately reported because it is for a reason related to the visit that occurred within seven days prior to the service.
3. A patient who received a telemedicine visit reported with 99214 95 requests an online digital E/M service due to increasing symptoms four days after the visit. The request for the online E/M service is not separately reported because it occurred within seven days of the telemedicine visit.
4. A patient who underwent a minor procedure in a family physician’s office on Monday receives on online message from the physician inquiring about any complications or concerns. The service was not patient-initiated and therefore is not separately reportable (even if the procedure had a zero-day global period).
5. A patient who underwent a minor procedure in a family physician’s office initiates an online digital E/M service within the procedure’s assigned global period (e.g., 10 days) requesting advice on wound care. The service is part of the procedure’s global service and not separately reported.

— Cindy Hughes, CPC, CFPC, is an independent consulting editor based in El Dorado, Kan., and a contributing editor to FPM

Posted on Aug. 18, 2023