Neurology & Pain Management Coding Alert

Curious if any payers are reimbursing 0074T? Here's your answer

You can capitalize on your neurologist's Internet interactions with patients by using the Category III code 0074T and receive well-earned reimbursement -- but before you do, you need to know what you have to provide to meet payer guidelines.

Code 0074T Describes High-Tech E/M

You can report and bill for electronic communications with your established patients using 0074T (Online evaluation and management service, per encounter, provided by a physician, using the Internet or similar electronic communications network, in response to a patient's request, established patient).
 
-We recently read an article in our local newspaper regarding doctors who are using e-mail to answer patients- medical questions and getting paid for it,- says Amy Robinson, coder for Roger Rholdon, MD, in Hammond, La.
 
CPT released 0074T in July 2004 as a category III code. These temporary codes identify emerging technologies, procedures and clinical trials. Using this code allows the AMA and insurers to gather data about these services or procedures.

Some Insurers Cover Online Communication

Good news: Some insurers have already agreed to pay as much as $25 for each 0074T claim. For instance, Blue Shield of California and BCBS of Tennessee reimburse for the online E/M services. These insurers maintain their own coverage guidelines. BCBS of Tennessee, for example, requires the following criteria for 0074T payment:
 
1. Physician responds to the patient's request within 24 hours (except over the weekend, in which case he responds by end-of-day Monday).
 
2. And one or more of the following:
 
- Patient describes new symptoms and requests intervention and/or advice from physician to treat new symptoms.
 
- Patient describes ongoing symptoms from a recent acute problem or chronic health problem and requests intervention and/or advice from physician to treat said problem.
 
- Evidence that physician gives substantive medical advice, revises treatment plan, prescribes/revises medication, recommends additional testing, and/or provides self-care/patient education information for a new and/or chronic health problem.
 
- Evidence that physician makes a new diagnosis and prescribes new treatment.
 
- Patient requests interpretation of lab and/or test results with evidence that physician provides substantive explanation and possibly makes recommendations to modify treatment plan, revises medications, etc.
 
- Evidence that physician provides extended personal patient counseling that changes the course of treatment and impacts the potential health outcome.

Aetna and AFLAC do not now reimburse 0074T claims, says Carmel Schmidt, a healthcare consultant for Dermody, Burke & Brown Medical Management Services LLC in Syracuse, N.Y.
 
Best practice: Check with your major payers for their specific guidelines on 0074T reimbursement.

NCCI Bundles Internet Encounter Into Visit

You should also ask your insurer whether it has adopted the National Correct Coding Initiative's policy on the high-tech code. NCCI makes 0074T a component of every other E/M code (except for code 99499, Unlisted E/M service).
 
Translation: You cannot separately report 0074T and an E/M code on the same date without a modifier, such as 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).
 
-This makes sense,- says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver. -Typically, your physician won't see the patient and also bill for an online evaluation on the same day.-

Examples Show Included, Billable Online Service

If an online encounter precipitates or results from a same-day, face-to-face encounter, consider the online service part of the other service's pre- or postservice work. In this case, you should not separately report the high-tech service, according to the CPT guidelines preceding 0074T.
 
Example 1: Your pediatric neurologist uses the Internet to maintain contact with parents of several of his cerebral palsy patients who live in rural areas far from his office. A mother of an 8-year-old spastic quadriplegia patient e-mails your provider to ask about possible side effects and drug interactions from medications that her daughter is taking. The mother wants to know if she should bring her daughter in to be seen. The physician says yes, and the mother makes a same-day appointment at your practice.
 
Solution: The neurologist should roll the online encounter into the in-person visit and bill one E/M, such as 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...). The physician can use the e-mail communication work as a part of either the history of present illness or medical decision-making.
 
Example 2: One week following the office visit, the neurologist responds to the mother's Internet contact regarding how the change in medication is working and makes recommendations for the patient's home health therapist. He recommends changes in the exercise program to improve range of movement and strength in the daughter's legs. He requests that the mother contact him again in two weeks unless she notices a change in her daughter's condition.
 
For the neurologist's response to this online inquiry, you would report 0074T.

Online Services Require Storage, Summary

When using 0074T, remember these two correct coding requirements:
 
1. You must permanently store the records. CPT's notes describing an online medical evaluation (0074T) state that the services -must involve permanent storage (electronic or hard copy) of the encounter.-
 
2. Include all communication, such as telephone calls, prescriptions and laboratory orders, pertaining to the encounter in your documentation.

Consider Other Online Consult Methods

Neurologists whose state insurers do not reimburse 0074T may consider using an online consult program such as Medem.com. -A patient who wants an online consult can make the arrangements through the Web site, pay for it with a credit card, and set up a time when the appointment will take place,- says Richard H. Tuck, MD, FAAP, a physician at PrimeCare of Southeastern Ohio.
 
-Initiatives are under way to comprehensively revise non-face-to-face coding and reimbursement, including Internet and phone services,- Tuck says. Neurology Coding Alert will provide updates as these changes take effect.