Pediatric Coding Alert

Your pediatrician can address simple issues on the Net--and get paid

Your patients may love the timesavings and the hassle-free benefits online E/M services can provide, and your pediatrician may love 0074T’s potential reimbursement, if you know when to use the high-tech code. 1. 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.

2. Some Insurers Cover Online Communication Good news: Some insurers have already agreed to pay up to $25 for each claim with 0074T. 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 is giving substantive medical advice, revising treatment plan, prescribing/revising medication, recommending additional testing, and/or providing self-care/patient education information for a new and/or chronic health problem.

• Evidence that physician is making a new diagnosis and is prescribing new treatment.

• Patient requesting interpretation of lab and/or test results with evidence that physician is providing substantive explanation and possibly making recommendations to modify treatment plan, revising medications, etc.

• Evidence that physician is providing extended personal patient counseling that is changing the course of treatment and impacting 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. 3. NCCI Edits Bundles [...]