Primary Care Coding Alert

When your FP provides services to a patient via the Internet or other electronic means, he can save valuable time and effort. This arrangement also benefits patients because "E visits" can spare them a trip to the office.

Did you know? Even though the visit isn't face-to-face, you can still collect deserved payment in many instances -- if you use the correct codes.

Check this out: Researchers at the University of California-Berkeley and Stanford University evaluated the impact of Web visits on physician and patient satisfaction and healthcare costs. Participants included 282 physicians, 3,688 patients, and a matched control group. The study demonstrated "consistent costs savings [and] strong statistical significance," found lead researcher Laurence Baker, PhD, chief of health services research, Stanford University School of Medicine.

Physician satisfaction ratings exceeded 90 percent among the highest-volume users. And more than three-quarters of the patients gave the service high marks, compared to telephone calls or office visits. For the five-month study period, physicians completed more office visits and produced more relative value units (RVUs) compared with the five-month control period from the previous year.

Here's the expert scoop on how you can code and get paid for some of your physician's electronic communications with patients.

Electronic communications between physician and patient come in two types: online E/M services and telemedicine. Online E/M visits, consultations and Web-visits all fall under the term "e-visit," which is "a structured non-urgent consultation between a doctor and an established patient conducted over the Internet," says Linda Bishop, CPC, CSS, CHC, corporate compliance officer for a physician management group in Los Angeles.

History: A code to recognize e-visit services became available when the AMA released 0074T-in 2005.

If the AMA grants approval in November, you may see that this code is deleted from CPT 2008 because the service is no longer considered "emerging technology." You may instead use a new category-I code with a seven-day pre-global period.

What you have to know: According to CPT guidelines, the physician must reply to the patient's online inquiry in a timely manner. Your practice must have permanent storage, either electronic or hard copy, of the encounter. Also, you can report this code only once during a seven-day period for any and all replies related to the patient's question.

Watch out: If the physician has seen the patient for this problem within seven days of the online query, you should not bill the Internet communication. Instead, you would consider it part of the post-service work attached to the billed E/M service.

You should also forgo reporting the new e-visit code if the patient's inquiry is regarding a recent surgery or procedure and you are still in the post-op period for that particular service.

The use of this code represents the sum of all communication with the patient regarding the online query -- that is, related telephone calls, providing prescriptions, ordering lab tests, etc., which you would then not bill separately. Because Medicare does not pay for non-face-to-face encounters with the patient, it remains to be seen if they will consider coverage for the new code. However, a number of private carriers now cover e-visits.

Florida's Blue Cross Blue Shield offers coverage for "online office visits" and outlines its newly reviewed policy at http://mcgs.bcbsfl.com/index.cfm?fuseaction=main.main&stage=pub&format=cfm&doc=E-Medicine.

Physicians can use e-visits in a number of ways to help their patients. Study these examples -- and don't forget that patient information should come from established patients and go though a secure, HIPAA-compliant site with encryption.

Example 1: An established patient (non-Medicare) with hypertension is taking a new medication to control his condition and is experiencing dizziness, nausea and fatigue. He e-mails the FP about his symptoms, along with a list of his blood pressure readings since changing the medication 10 days ago. The patient asks if he should come in for an office visit or if the FP should change his medication.

The FP reviews the patient's symptoms along with his chart history and pressure readings, and suggests the patient is suffering from rare side effects to the medication. He replies to the patient's e-mail and directs him to online information on the drug. The physician also tells the patient he is calling in a new prescription that will not cause these side effects.

You would code this visit with the new E code and list the appropriate hypertension diagnosis code, such as 401.x (Essential hypertension), along with 995.2x (Other and unspecified adverse effect of drug, medicinal, and biological substance).

Example 2: An established, non-Medicare female patient e-mails her FP requesting information on breast cancer after learning several female family members developed the disease. The patient asks if she should get a screening mammogram.

The physician responds to the e-mail and explains the implications of family breast cancer history and gives his opinion as to whether a mammogram is necessary. The FP refers the patient to several online sites on the subject and attaches several documents on the subject.

You would report this patient interaction with the new category-I E code linked to V16.3 (Family history of malignant neoplasm; breast) and V65.49 (Other counseling, not elsewhere classified; other specified counseling) to reflect that the encounter was prompted by the patient's request for health advice based on a family history of breast cancer.

You need to remind your physicians to be careful about their e-mails to patients and the information they contain. When both physician and patient use unencrypted e-mail, parties who should not have access to this medically sensitive information may be able to access it.

When using e-mail to communicate with patients, remember these important guidelines:

- Communications should be with established patients in non-urgent circumstances only.

- You must keep a copy of the exchange, either on paper or on a hard drive.

- Appointment reminders, prescription refill requests and lab results cannot be classified as e-visits.

"If you-re going to bill for it, it shouldn't be an administrative transaction like that," says Daniel Sands, MD, of Beth Israel Deaconess Medical Center in Boston.

Remember: If you-re using unencrypted e-mail, you should not include protected health information (PHI) by avoiding discussion of "things like HIV, STDs, substance abuse, domestic violence, and psychiatric illness," Sands says.