WASHINGTON — Pediatricians can soon expect practical help with the reimbursement of telephone care when the American Academy of Pediatrics releases a policy statement and toolkit on the subject later this year, Dr. Andrew Hertz said at a meeting sponsored by the American Academy of Pediatrics.
The reimbursement of telephone care has been a hot topic among pediatricians in the last few years, with good reason. “Pediatrics practices more medicine over the phone than any other specialty,” said Dr. Hertz, a member of the AAP's section on telephone care executive committee. In pediatric practices, approximately 30% of patient contact during office hours and 80% of after-hours care is delivered via telephone.
Dr. Hertz, who is also the medical director of the pediatric call center at Rainbow Babies and Children's Hospital in Cleveland, offered a preview of the upcoming policy statement.
Earlier this year, new CPT codes were introduced for care-plan oversight of patients who are not under the care of a home health agency. These codes can be used for individual physician supervision of patients in the home (or at another location) who require complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans; for communication—including telephone calls—for purposes of assessment or care decisions with health care professionals and family members involved in the patient's care; and for the adjustment of medical therapy.
Code 99339 can be used for 15–29 minutes of such care within a calendar month and code 99340 can be used for more than 30 minutes. However, there are no relative-value units for these codes yet.
These new codes are ideal for telephone management of chronic disorders such as asthma, ADHD, obesity, eating disorders, and diabetes.
“Even if you have nurses in your office who are interacting with patients and you then review those telephone calls with them, you can use this for your total time,” said Dr. Hertz.
The current CPT codes for telephone calls by a physician to a patient or health care professional for consultation, coordination, or management include 99371 (simple or brief), 99372 (intermediate), and 99373 (complex or lengthy).
The American Medical Association's CPT Advisory Committee is currently working on the development of a code structure for telephone care, according to Dr. Joel F. Bradley Jr., a pediatrician and member of the CPT Editorial Panel. Dr. Hertz asked Dr. Bradley, who was in the audience, to comment on the status of CPT coding for telephone care.
“The issues [including what the best code structure is] have to be clarified … but the big issue is, how do you exclude that postservice and preservice payment we're already getting in our E/M [evaluation and management] codes from the CPT codes,” said Dr. Bradley.
Managed care companies often consider telephone care to be part of pre- and postvisit care as well.
Therefore, every office visit reimbursement has some money factored in for things like phone time and appointment scheduling.
A few managed care companies are starting to reimburse for telephone care, although the rates vary, said Dr. Hertz. “Even if it doesn't get paid by the insurance company, it's worth your while to be doing this. Document it. It lets the insurance companies know that we're doing this—that we have a method in place,” said Dr. Hertz.
For pediatricians who do decide to charge for some telephone care calls, the first decision is what type of calls will be charged.
Possibilities include:
▸ Office-hour calls or after-hours calls, or both.
▸ Calls that are handled by a physician (or a physician's assistant or a nurse practitioner), or calls that are handled by a nurse but overseen by a physician.
▸ Urgent or nonurgent calls.
▸ Calls during special telephone care hours that are set aside for scheduled phone appointments.
Other types of calls to charge for include services that involve a new treatment (and avoid the need for an office visit); chronic medication management; chronic disease flare management; reporting laboratory results that necessitate a management change or a referral; extended behavioral counseling; and follow-up calls to an office visit.
One of the key decisions to make is how to handle the timing of a call in relation to an office visit. “So if you talk to someone on Friday night and they're seen Saturday morning, are you going to charge for the Friday night call? It's a decision you'll have to make,” said Dr. Hertz.
The draft statement—subject to approval by the board of directors—recommends charging during and after office hours for:
▸ Calls for physician management of a new problem, including consultation, medical management, and coordination of care not resulting in an office visit within 24 hours.
▸ Calls for physician management about an existing problem for which the patient was not seen in a face-to-face encounter in the prior 7 days.
▸ Calls related to care plan oversight (charged per month).
“What this is doing is getting away from the fact that people feel the pre- and postvisit telephone care is part of the E/M code for that visit,” said Dr. Hertz.
Notifying patients and families before initiating the new charges is the next step. Practices that did not notify patients before starting to charge for telephone care had considerable whiplash in feedback, noted Dr. Hertz.
Sending a letter to all patients may be cost-prohibitive. Alternatives include sending letters only to new patients or at the identification of a chronic disease. Letters can be mailed, included with billing statements, or given out in the office during a visit. Another option is to notify patients during their first billable call that they will not be charged for this call but that they will be billed for similar calls in the future.
Other means of notifying patients include posting signs in the office; providing office handouts or brochures with alternative sources of good medical information, such as Web sites and books; recording messages for the answering service; and having the receptionist notify callers of the new policy at the time of a telephone call.
Notification content should include an explanation of the types of calls being charged, information about insurance coverage and patient responsibility, a statement that care will not be denied over the telephone, and a reminder that patients always have the option of seeing the physician in the office.
It's also important to explain the concept of telephone care. “Here's where you have to do some marketing. I think this is honest, and it's not twisting the truth; it's just taking the correct angle,” said Dr. Hertz.
Point out that telephone care is a national trend that can be cheaper for patients, insurers, and employers, thereby reducing the total cost of health care. Emphasize that telephone care is more convenient for patients and families because it can replace some types of office visits, but it does require physician expertise.
Telephone call documentation should include the date and time of the call; the patient's name and date of birth; the reason for the call; any relevant history and evaluation; the type of service and call disposition; the total call duration; and applicable CPT codes. Charts or telephone logs must be retrievable.
In terms of billing and collections, pediatricians charging for phone calls will need to establish policies on how to manage Medicaid patients, first-time callers, personal payment responsibility, and copays.
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