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 Internet Encounter Into Visit

You should also ask your insurer whether it adopted the National Correct Coding Initiative’s latest policy on the high-tech code. The NCCI version 11.0 made 0074T a component to every other E/M code (except 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 modifier 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.”

4. 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 post-service work. In this case, you should not separately report the high-tech service, according to the CPT guidelines preceding 0074T.

Example 1: A patient’s mother e-mails your pediatrician to ask about her daughter’s abdominal cramping (such as 789.00, Abdominal pain, unspecified site) and wants to know if she should come in. The physician says yes, and the patient makes a same-day appointment at your practice.

Solution: The pediatrician would roll the online encounter into the in-person visit and bill one E/M, such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...). The physician can use the e-mail communication work as either a part of the history of present illness or a part of the medical decision-making. 

Example 2: Suppose the pediatrician e-mails the patient and instead recommends over-the-counter treatment with in-person follow-up if the patient’s problems don’t resolve. For the pediatrician’s response to the patient’s online inquiry, you would report 0074T.

5. 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 including telephone calls, prescriptions, and laboratory orders pertaining to the encounter in your documentation.

6. Consider Other Online Consult Methods

Pediatricians 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 pediatrician 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. Pediatric Coding Alert will provide updates as these changes take effect.