Ob-Gyn Coding Alert

Although most ob/gyns spend considerable time on the phone with patients and CPT has codes for this service, the fact is that telephone calls do not get reimbursed. Is there any recourse to this rejection by the insurance industry?

CPT codes for telephone calls include:

99371 (telephone call by a physician to patient or for consultation or medical management for coordinating medical management with other health care professionals [e.g., nurses, therapists, social workers, nutritionists, physicians, pharmacists]; simple or brief [e.g., to report on tests and/or laboratory results, to clarify or alter previous instructions, to integrate new information from other health professionals into the medical treatment plan, or to adjust therapy]).

99372 ( ... intermediate [e.g., to provide advice to an established patient on a new problem, to initiate therapy that can be handled by telephone, to discuss test results in detail, to coordinate medical management of a new problem in an established patient, to discuss and evaluate new information or details, or to initiate new plan of care])

99373 ( ... complex or lengthy [e.g., lengthy counseling session with anxious or distraught patient, detailed or prolonged discussion with family members regarding seriously ill patient, lengthy communication necessary to coordinate complex services of several different health professionals working on different aspects of the total patient care plan])

A Common Practice

Few ob/gyns would look at the above codes and not be able to think of countless times that they have provided this type of service to a patient. So why do Medicare and virtually all commercial insurers reject these codes when submitted for reimbursement? Medicares guidelines for the codes, as excerpted from the Medicare Carriers Manual, spell out the policy succinctly:

Telephone Calls Do not pay for telephone calls (codes 99371-99373) because payment for telephone calls is included in payment for billable services (e.g., visit, surgery, diagnostic procedure results).

Commercial carriers also take the position that telephone calls are included in the evaluation and management (E/M) visit or global care period, and simply are not something for which they should have to reimburse a physician. Yet providing telephone support to patients is an essential part of every ob/gyn practice. Often, patients need extra counseling even reassurance from their physician when discussing test results or treatment plans. Geographic challenges, scheduling conflicts, or even apathy on the patients part can make telephone contact a needed alternative to the face-to-face office visit.

Seetha S. Aiyar, MBA, administrator to the Cleveland Clinic Foundation department of gynecology & obstetrics, a 27-physician/midwife staff practice in Cleveland, sees no ambiguity in the need for patients to have phone access to their physicians and vice-versa. In many cases, says Aiyar, the ob/gyn is the only primary care provider a woman sees. Naturally, she will have many questions subsequent to her visit with the doctor, and we as a practice have chosen to provide this service via telephone where applicable. Aiyar says that very often, patients resist coming to the office and try to insist that the physician speak to them on the phone instead.

Patricia Horvatich, office manager for Robyn M. Cook, MD, a solo practitioner in Kealakekua, Hawaii, frequently deals with patients who are reluctant to schedule an office visit. I tell patients who refuse to come in, says Horvatich, but who want the doctor to call for a five-minute discussion, that we will bill for the phone call. Once patients realize that phone calls are not covered by their insurance, they opt for an office visit instead. But Horvatichs case is a good example of geographic challenges to face-to-face patient care. Her practice is located on the west coast of the Big Island of Hawaii, which got its name for a reason. A patient on the eastern side of the island may well push for a phone call to avoid the 80+ mile drive over mountainous terrain to her doctors office.

No Billing Option Is Ideal

The widely acknowledged fact that no one who submits a claim for a telephone conversation between patient and doctor will get paid leaves several less-than-ideal options for payment. Practices can:

1. bill the patient directly (informing them that you will do so before the call takes place);

2. document the call and review it as part of medical decision-making at the next visit;

3. triage all calls to cut down or eliminate physicians on the phone;

4. make appointments to discuss test results at the time they are ordered and then, if they are normal, call the patient to cancel the appointment; or

5. figure that the cost of the calls is part of overall practice overhead.

Melanie Witt, RN, CPC, MA, independent consultant and former program manager for the American College of Obstetrics and Gynecologys (ACOG) department of coding and nomenclature, states that all of the above potential solutions have been presented at the ACOG physician coding workshops since the codes were added to CPT. Witt recommends that the practice adopt the method that best suits the practice and its patient population. If you are going to be billing the patient, be sure that the insurer considers the service to be non-covered, not as an integral part of an evaluation and management (E/M) service, Witt cautions.

Billing experts agree that getting insurers to pay for telephone calls between doctor and patient is almost impossible. But is Horavitchs suggestion of billing the patient for the physicians phone time a reasonable solution? If the insurance rejects this service, but the patient insists on phone time with the physician, says Horavitch, then it seems like the patient should be responsible for paying.

Dianne Wilkinson RHIT, CPHQ, the quality manager and compliance officer for MedSouth Healthcare, a multispecialty, multilocation group based in Dyersburg, Tenn., also suggests practices wishing to bill their patients for phone calls do so with caution. Until the latest Medicare update seminar by my Tennessee carrier, says Wilkinson, I too was under the impression that since phone calls were a non-covered service, my doctor could bill the patient if he decided to make such a policy. Wilkinsons carrier told her this was not possible because telephone calls are considered bundled into Medicare reimbursement for E/M or global follow-up care. So as far as Medicare is concerned, at least in Tennessee, she says, we can consider the calls a freebie.

Other experts agree that ob/gyns should check with the individual carriers before attempting to bill patients because the insurance companies may have policies in place regarding doing so. Call coverage tends to be a thorny issue, says Thomas Kent, CMM, principal of Kent Medical Management, a practice management and coding consulting firm in Dunkirk, Md. Many HMOs consider call coverage to be an issue among the physicians and not billable to either carrier or patient. You will need to check your contracts or talk with the provider services representative before sending a bill to the patient.

Is Help on the Way?

CPT codes for telephone calls were added in 1992, and some coders think that reimbursement for these codes may not be far away. Increasingly, physicians are appealing both to insurance companies and to their medical specialty advocacy groups to challenge the status quo. Doctors are beginning to ask for relief with this payment issue, says Diane Brooks, CPC, coding and compliance manager for Fornance Physician Services, a multispecialty group with 75 physicians in Norristown, Pa. Hopefully, pressure from their member physicians will move medical societies to approach payers on this issue to reverse current policy.