EM Coding Alert

Knowledge Check:

These Codes Got Heavy Use During the PHE —Now What?

Published on Fri May 19, 2023

Support the codes you want to use with the documentation they require.

We’re exploring a whole new world now that the COVID-19 public health emergency (PHE) is officially over.

Find out how to navigate virtual encounters and review these digital evaluation and management (E/M) to set your practice up for success.

Understand Context of Codes

An e-visit is a patient-initiated digital encounter that takes place through a secure online portal. There are two sets of codes. One is for encounters between a patient and physician:

99421 (Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes)
99422 (…11-20 minutes)
99423 (… 21 or more minutes)

The other is for encounters between a patient and another qualified healthcare professional (QHP):

98970 (Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes)
98971 (…11-20 minutes)
98972 (… 21 or more minutes)

Coding alert: CPT^®added 98970-98972 to the code set in 2021 to allow you to report digital patient assessment and management for QHPs who can’t report E/M codes 99421-99423, which are limited to physicians.

Remember 7 as the Magic Number

The potentially tricky part about these codes is keeping track of when and whether to report the service. These codes are exclusive to established patients and may include time spent for interaction for up to seven days. This means that providers must document the time associated with each interchange in order to add up the time spent at the end of the seven-day period. Therefore, you won’t bill for these encounters as soon as they occur.

Additionally, “if the inquiry is related to a surgical procedure within a global period, then the service is not reported. The provider therefore must keep a permanent record on file. Other rules apply and are listed in the CPT^®manual,” says Natalie Ruggieri-Buzzelli, CPC, CGSC, HIM, coding specialist at the Hospital of the University of Pennsylvania.

Check NCCI Edits for Clarification

For further clarification of this seven-day rule, turn to the National Correct Coding Initiative (NCCI) edits. CPT^®considers that digital service to be part of a related E/M visit if the digital service falls within seven days of the encounter.

You’ll see that while 99421-99423 are Column 2, or component, codes to 99202-99215 (Office or other outpatient visit for the evaluation and management of a/an new/ established patient …), the edit pairs all have 0 modifier indicators, meaning that you cannot use an NCCI-associated modifier to unbundle the services.

Note these exceptions: 99422 and 99423 are not paired with 99202-99205. For the established patient E/M codes, things are a little more complicated, as 99421-99423 are not paired with 99211, while only 99421 is paired with 99212.

Conversely, when 99422-99423 are the Column 1, or comprehensive, codes, NCCI has only paired them with 99211 and 99212, with each pair having a 0 modifier indicator. However, as a Column 1 code, 99421 only has a 0 indicator with 99211. The codes are not paired with any of the other 99202-99215 codes.

Why? “When 99421-99423 are paired up with the 99202-99215 codes, some edit pairs have the 99421-99423 codes in Column 1, and some edit pairs have them in Column 2,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “I believe CMS has decided which code is the Column 1 code in any given combination based on which of the two codes in the pair has a higher work relative value unit [RVU], indicating a more extensive service,” Moore continues.

Pro coding tip: Despite these exceptions, there are still many instances when 99421-99423 and 99202-99215 are not code pairs. This means that you will be able to claim an online digital E/M with an office visit on the same date of service. To do so, you must be able to justify that the two services are not related in any way.

Document the Encounter Like This

Let’s say an established patient contacts your provider through their patient portal one month after having discussed treatment options for chronic constipation. The doctor had previously recommended a change in diet, including a drastic increase in fiber and the addition of an over-the-counter (OTC) stool softener and a check-back in 6 months. However, after 30 days, the patient reports little has changed. The doctor reviews the information and prescribes a trial of linaclotide.

This is a situation where you can bill 99421, if the encounter lasted 5-10 minutes, but make sure the physician documentation includes the following:

patient consent, proof the encounter was patient-initiated
patient location
chief complaint/reason for encounter
justification for services
pertinent history
medical decision making
applicable diagnoses
duration of encounter(s) within the 7 days

End of PHE Shouldn’t Affect Code Use

While these codes have taken some getting used to because of the documentation requirements, the good news is that there’s probably no reason to expect they’ll go away or that the Centers for Medicare & Medicaid Services (CMS) will stop paying for them. “I fully expect both of those code families to be covered and paid by CMS, just as they are now,” says Moore.

This is because 99421-99423 were actually added to CPT^®prior to the pandemic. This code set was part of the 2020 Medicare Physician Fee Schedule (MPFS), which means they were thought up and published well before lockdown. “Furthermore, [the] PHE has not really impacted how the codes are delivered. They were online digital E/M codes when they were created, they still are, and they will continue to be after the PHE ends,” Moore continues.