Pediatric Coding Alert

Use this FAQ, know when you can, cannot bill for telephone E/Ms.

If your pediatrician is spending more and more time on the phone talking to parents or even patients, and you’re not familiar with the virtual check-in codes, then you could be missing out on a small yet valuable boost to your bottom line.

And if you are familiar with the codes, you need to make sure you understand exactly how to use them, so you can avoid denials and get reimbursed for the service. So, we’ve provided this FAQ to help you understand the codes and their parameters, so you can use them effectively.

What Is the Difference Between 99441-99443 and G2012?

First, let’s take a look at the CPT^® codes in question and their Medicare-recognized equivalent

• 99441 (Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion)
• 99442 (… 11-20 minutes of medical discussion)
• 99443 (… 21-30 minutes of medical discussion)
• G2012 (Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion).

There are three major differences between the CPT^® and HCPCS codes that you should understand before you use them. First, “Per CPT^® guidelines preceding 99441-99443, the patient or guardian must initiate the call, whereas the physician/QHP can initiate the G2012,” observes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Second, “G2012 is for a ‘technology-based service,’ which means it’s not limited to telephone and could be computer-based,” Moore elaborates. And third, “the CPT^® codes cover longer calls, which is a great advantage to use them if the service meets the definition of, and guidelines associated with, 99441-99443 and the payer in question pays for them,” Moore adds. 

What Limitations Are There on the Codes?

The most obvious limitation is that none of these services can stem from, or result in, an evaluation and management (E/M) service for the patient. If that happens, then the calls or emails will be bundled into the E/M, and you will not be reimbursed separately for the calls or emails.

Coding alert 1: The exception to this limitation would be if your provider saw the patient for an E/M before or after the check-in for an entirely different reason unrelated to the call. So, for example, if a patient came in for an E/M related to otitis media, then the patient’s mother checked in less than a week later to discuss changing the patient’s asthma medication, then you would be able to bill separately for the G2012 or 99441-99443.

In addition, “unlike G2012, 99441-99443 cannot be used for asynchronous services such as email. The appropriate code for that would be 99444 [Online evaluation and management service provided by a physician or other qualified health care professional who may report evaluation and management services … using the Internet or similar electronic communications network],” says Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

Coding alert 2: If you use 99444, be aware that it has a zero-dollar value, so payers will not reimburse your provider for this service.

Do I Use Modifiers for the Service?

Even though these services describe telemedicine services, there is no need to add a telehealth modifier to the codes. “Any modifier for these codes would be situation specific — for example, if you needed to appropriately override a National Correct Coding Initiative [NCCI, or CCI] edit,” says Moore. And modifier use, along with reimbursement for the codes, would also be payer-dependent, so you would want to check beforehand what codes your payer will accept and how you should bill for them.

Can You Bill These Services Incident-to?

“As incident-to is typically a Medicare concept, and as Medicare doesn’t cover 99441-99443, you can’t bill them ‘incident to,’ says Moore. Also, “the code descriptor in each case explicitly says, ‘provided by a physician or other qualified health care professional,’ which suggests having another member of the staff do it ‘incident-to’ is inconsistent with the intent of the codes,” Moore adds.

However, “should your office wish to bill for telephone services provided by a qualified nonphysician who may not report evaluation and management services, you can use 98966-98968 [Telephone assessment and management service provided by a qualified nonphysician health care professional …] for calls and 98969 [Online assessment and management service provided by a qualified nonphysician health care professional …] for technology-based interactions” Holle suggests.