Be careful when charging for patient portal messages

Jonathan Rubenstein, MD

I read that Cleveland Clinic is now billing for portal messages and just received an email that our local hospital is doing the same thing. We are in a private urology group unaffiliated with the hospital. Can we start billing for portal messages?

You are referring to the announcement that on November 17, 2022, the Cleveland Clinic Foundation started billing for some messages sent from its MyChart portal.¹ We can all agree that the number of portal messages received by practices is growing, which has both positive and negative implications for work and workflow in the office. Therefore, the idea of billing for portal messages created a lot of buzz. The good news is that some of

Mark Painter

these interactions are billable; however, not every message can be charged. As with everything, the devil is in the details.

There are differences in billing for portal messages, currently allowed telephone services, and virtual evaluation and management (E/M) services. For the busy medical practice, every minute counts. Providing quality medical care, trying to meet patient demand, and maintaining practice profitability is a balancing act. With the increase in portal messaging, some physicians would like to notify patients about a potential charge, even if it is a nonbillable message, merely to reduce the portal traffic. Others have found the use of portal messaging for appropriate care a tremendous asset to the practice and to their patients. In this new normal of medical practice, we would like to do a deeper dive into this topic to help those who are considering billing for portal messages by answering the following questions: Are there CPT codes that describe online E/M services? If so, what do they say? What are the rules and restrictions, and when can these messages be billed? Do patients need to give consent? Are patients charged? Does billing for these services lead to concerns about surprise billing, fraud, and insurance contract concerns? Are there medicolegal concerns? How are portal messages best used in the practice of urology?

Three CPT codes can be used to report online digital evaluation and management services:

99421: Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 5-10 minutes

99422: Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 11-20 minutes

99423:Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 21 or more minutes

These online digital E/M services can be reported when a provider performs appropriate E/M for an established patient and the services are differentiated by the amount of time spent over a period of 7 days. The online interaction must essentially provide the same services as an in-person or telemedicine interaction but by Health Insurance Portability and Accountability Act–compliant means such as a patient portal. It is a true E/M service and must be performed in lieu of another visit. The interaction must be medically necessary. It is typically patient initiated and responds to a new or worsening problem, but it is managed appropriately without needing a telemedicine or in-person interaction. The interaction should include a medically appropriate history, a note about reviewing results and ordering testing, and the patient treatment performed. The service must take a minimum of 5 minutes of physician time, and clinical staff time cannot be used as part of that time. This means that answering simple questions in less than 5 minutes of provider time cannot be reported. The service can only be reported once every 7-day period, and the time should be combined if more than 1 portal service/interaction is required to perform the services within that 7-day period. It cannot be reported on the same date when the provider reports other E/M services.

What cannot be reported? Portal messages that aren’t true E/M services cannot be reported. For example, answering simple questions that take less than 5 minutes, communicating test results, calling in medication refills, changing medications due to cost or formulary, handling messages that do not require clinician expertise, and scheduling appointments do not qualify. If the online communication results in an in-person visit within 7 days, the time or complexity of the portal message work is incorporated into the code selection of the in-person visit and the online service is not reported. One should not report these services if within a global period of a surgical procedure, unless unrelated.

What about patient consent? As always, it is important for patients to know what are and what are not billable services. Some institutions post their billing policies online and others may put them in their offices. However, patients rarely read these policies even when they sign them. Few patients are billing experts. Many patients believe that insurance covers everything and do not understand the nuances of what is and what is not billable, and few understand whether they will be charged or whether they may be responsible for a co-pay or coinsurance. And those already using portal services may think they have found a free access point to medical care. Therefore, we strongly recommend you clearly notify patients in advance that if they choose to receive online E/M services, they may be billed and have the option of considering an in-person or telemedicine service. Many have found that multiple notifications are required, including messaging in the patient portal. You should document this type of communication in addition to the clinical information required. In our experience, patients who receive surprise bills, no matter how small, tend to be dissatisfied and are more likely to report dissatisfaction to their insurers. There is no such thing as too much communication. In fact, we have heard many stories of patients refusing to pay for online or telehealth services who then demand these services within days of refusing to sign agreements. In addition to effective and voluminous messaging and education, it is important to stick to your policies. Inconsistent application of these policies will lead to patient dissatisfaction, problems for your staff, and even more dire circumstances.

Is there a potential cost to patients? Of course. Their direct out-of-pocket costs depend on their insurance coverage, co-pay, and deductible status. Even if this is a covered service, patients may have an out-of-pocket charge, which makes consent and communication of the intent to bill even more important. For Medicare, if it is a covered service, like other services you provide, the patient may be responsible for at least 20% of the cost of the service if they do not have secondary insurance.

Is there a fraud and insurance contract risk? Of course. Anytime one bills a government payer for services, there is a risk of fraud if the criteria for billing are not met. One could also be at risk for audits and takebacks for incorrect use of these codes. Therefore, understanding what is reportable and having documentation to back up the submitted codes is of utmost importance. Private payers also have rules for use of these codes that are governed by your contracts; misuse could lead to takebacks, exclusion from plans, or worse.

Is there a medicolegal risk to performing digital E/M services? Of course. Anytime there is a patient interaction, there is risk. The biggest risk for these services is the lack of verbal and visual communication that occurs with a telemedicine or in-person E/M interaction. Physicians should strongly consider recommending an in-person visit in any patient interaction if the patient needs be seen and/or examined for their concern. As we all know, there is no inflection in digital communication, so there are concerns for miscommunication. In short, this type of service should be reserved for those patient interactions where you are confident you can clearly understand the patient’s needs and clearly communicate your instructions.

Can one add digital E/M encounters to one’s business? There is path to reimbursement. Many practices are seeing increased messaging, and demand for these types of services is growing. Both are key ingredients to any successful business line. With any new line of business, a group will need to determine what can be supported and how to market these services to patients. Before rolling out a new service line, the group will need to set parameters in which to operate, and these parameters may need adjustment by the patient. Although charging for these services may deter some patients from abusing the messaging system, it will likely create new challenges.

Conclusion

We agree that portal message traffic can be challenging. However, the portal represents an opportunity to expand services in a manner that may ultimately save time, increase patient satisfaction, and improve efficiency and outcomes. With opportunity, there is risk. In urology, certain patient conditions and disease states may qualify for billable online E/M services. To stay out of trouble, one needs to remember that these online E/M services are a substitute for an in-person E/M visit, requiring that billable portal-based services have a documented and medically necessary history, the ability to review and/or order pertinent tests, and a developed treatment and management plan. Portal services that are not billable can also represent an efficient way to support patient care and be successfully incorporated into the medical practice with careful planning and analysis. Understand the rules and plan carefully. Communicate clearly to your group and your patients.

Reference

1. MyChart messaging. Cleveland Clinic. Accessed February 16, 2023. https://bit.ly/3Pcvott

Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o Urology Times®, at UTeditors@mjhlifesciences.com.

Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.