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September 26, 2024

CPT® Codes (99421-99423) – and Payment for – Online Digital Evaluation and Management (E/M) Services

Or, as I call them: message, manage, message.

There are CPT codes for online digital E/M services.

• CPT developed a set of  CPT ® codes for use by physicians, physician assistants and advanced practice nurse practitioners performing brief, online E/M services via a secure platform
• There are also CPT® codes for use by clinicians who do not have E/M within their scope of practice codes 98970—98792
• CMS is requiring verbal consent for communication-based technology services (CBTS)
• This verbal consent is required annually, and encompasses all CBTS, not a consent for each service service or consent for each provision of the service
• These are not considered telehealth services, so do not use POS 02 and modifier 95. Why? they are not on CMS’s list of covered telehealth services, and do not use real-time, interactive audio-visual communication
• Everyday Coding Q&A – Licensed professional counselors and use of 99421–99423

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Watch the short video below to review the guidelines for coding online digital E/M services. The video includes a review of CPT codes for online digital E/M services, and HCPCS codes G2010, G2012, G2250, G2251, G2252. Read more about those HCPCS codes in the article linked at the bottom of this post.

CPT® codes for online digital E/M

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             11—20 minutes

99423             21 or more minutes

These codes are for use when E/M services are performed, of a type that would be done face-to-face, through a HIPAA compliant secure platform. They are not to be used for non-evaluative functions, such as test results, appointment scheduling  or other communication that doesn’t include evaluation and management. These are for established patients and require a patient-initiated communication. They may not be used for work done by clinical staff or for clinicians who do not have E/M services in their scope of practice.  They are “messaging” codes, not telephone, video or in person services.

Report these services once during a 7-day period, for the cumulative time. According to CPT ® ,

“The seven-day period begins with the physician’s or other qualified health care professional’s (QHP) initial, personal review of the patient-generated inquiry. Physician’s or other QHP’s cumulative service time includes review of the initial inquiry, review of patient records or data pertinent to assessment of the patient’s problem, personal physician or other QHP interaction with clinical staff focused on the patient’s problem, development of management plans, including physician  or other QHP generation of prescriptions or ordering of tests, and subsequent communication with the patient through online, telephone, email, or other digitally supported communication, which does not otherwise represent separately reported E/M service.” [1]

They begin with the patient-initiated portal message. The practitioner reviews the communication and the medical record and manages the problem. It may be a prescription, test, or advice.  Often, there is back and forth messaging, and all of the practitioner time in the 7 day period counts.

If the patient is seen in person or via telehealth within the 7 day, codes 99421-99423 are not reported. If the messaging relates to an E/M service that occurred within the last 7 days and is related to the problem for which the patient was seen, it is not reported. However, if a patient generates a message regarding a new problem during the 7 days after an E/M visit, and that doesn’t result in an E/M service, these codes may be used.

These are time based codes, with time ranges in the code descriptions. A practitioner may never use the same time period to meet requirements for two different services. They may not be reported on the same day as an E/M service. Look in your CPT book. There is a long list of “do not report” codes.

Other requirements:

• Verbal consent is required by CMS.
• The patient initiates the service with an inquiry through the portal.
• The service is documented in the medical record.
• If the patient had an E/M service within the last seven days, these codes may not be used for communication related to that problem.
• If the inquiry is about a new problem (from the problem addressed at the E/M service in the past 7 days), these codes may be billed.
• If within seven days of the initiation of the online service a face-to-face E/M service occurs, then the time of the online service or decision-making complexity may be used to select the E/M service, but this service may not be billed.
• These are for established patients, per CPT ® .
• This may not be billed by surgeons during the global period.
• The digital service must be provided via a HIPAA compliant platform, such as an electronic health record portal, secure email or other digital applications.

Additionally:

• These services may only be reported once in a 7-day period.
• Clinical staff time may not be included.
• Don’t double count time with any other separately reported services, such as care management, INR monitoring, remote monitoring. (CPT ® book has a list of codes)

Online services provided by clinicians who may not bill E/M services

CPT © codes for clinicians who do not have E/M services in their scope of practice, 98970—98972.  There is an editorial notation after codes 99421, discussed above, that says:

“For online digital E/M services provided by a qualified nonphysician health care professional who may not report the physician or other qualified health care professional E/M services (eg, speech-language pathologists, physical therapists, occupational therapists, social workers, dietitians), see 98970, 98971, 98972).” [2]

CMS has assigned these as active codes.

98970 Qualified nonphysician health care professional online digital assessment and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes

98971     11-20 minutes

98972    21 minutes or more

Question: Can a licensed professional counselor use codes 99421–99423 for digital management of a client initiated issue, such as a client-based email inquiry related to their therapy problem? Answer : No.

These codes appear in the Evaluation and Management section of the CPT® book, and are for use by physicians and other qualified health care professionals. The definition is “online digital evaluation and management service.” Licensed professional counselors do not have E/M services in their scope of practice. If a code is defined as an E/M service, it may only be performed by someone who has E/M in their scope; that is, someone who can perform an office visit or initial hospital service.

There are equivalent codes in the medicine section of the book. In the CPT® 2023 Professional Edition, these start on page 846. The heading is “Qualified Nonphysician Health Care Professional Online Digital Assessment and Management Service.” These codes do not use the words evaluation and management service.  They are 98970, 98971, 98972. Be sure to read the entire section at the start of the codes for the very specific CPT® instructions on their use.

It is confusing, because sometimes both CMS and CPT® use “physician” to include advanced practice nurses and physician assistants.

Virtual Communication: HCPCS Codes G2010, G2012, G2250, G2251, G2252

[1] CPT Professional Edition, 2024. AMA, Chicago, p. 39.

[2] CPT Professional Edition, AMA, Chicago 2024, page 39.

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Last revised April 1, 2024 - Betsy Nicoletti Tags: telehealth

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Home > Practice Resources > Reimbursement > Coding > Coding and coverage for telehealth and eVisits during the COVID-19 crisis

Coding and coverage for telehealth during COVID-19

Resources and guidance to help GI practices navigate new coding rules to ensure maximum reimbursement for telehealth/eVisit services. 

View additional COVID-19 resources here.

Featured COVID-19 coding resources

• Telehealth and virtual services coding guide (joint society) June 10, 2020
• Telehealth virtual physical exam tips (joint society) June 10, 2020
• AGA guide: Commercial telehealth coding policies   April 6, 2020

Top five things gastroenterologists should know about telehealth

The following guide was developed jointly by AGA, AASLD, ACG and ASGE.

During the COVID-19 health emergency, CMS expanded  access to telemedicine services, increasing payment for telephone evaluation and management (E/M) codes 99441-99443 to the level of office/outpatient E/M codes 99212-99214 ($46-$110). Previous rules expanded telehealth for all Medicare beneficiaries — not just those that have novel coronavirus — for the duration of the COVID-19 PHE, expanded payments for telehealth services to a variety of settings in addition to existing coverage for originating sites including physician offices, skilled nursing facilities and hospitals, allowed reporting for new patients was well as existing patients, and allowed two-way, real-time audio/visual telehealth services to be paid under the Medicare Physician Fee Schedule at the same amount as in-person services.

• Effective retroactively from March 1, 2020, national level payment for telephone (audio-only) E/M codes 99441-99443 will increase from $15, $31 and $39 respectively to $46, $56 and $110 to match office/outpatient E/M code payments for 99212-99214 (New in Medicare’s April 30 COVID-19  interim final rule with comment period  (IRC)). You must report 99441-99443 with modifier 95 and place of service (POS) where the visit would have taken place in person prior to the public health emergency (e.g., 11-Office, 22-Hospital Outpatient, 23-ASC) in order to get the higher rates. Claims without modifier 95 will be paid at the lower rates.
• E/M level selection for telehealth (real-time audio/visual) can be based on medical decision making or time and CMS has temporarily removed any requirements regarding documentation of medical history and/or physical exam in the medical record during the COVID-19 crisis.
• Most telehealth services can be provided to both new and established patients, including 99201-99215 and 99441-99443.
• Clinicians can provide remote patient monitoring services to patients with acute and chronic conditions and can be provided for patients with only one disease.
• Physicians can supervise their clinical staff using virtual technologies when appropriate, instead of requiring in-person presence.

Hospitals and a range of clinicians, including doctors, nurse practitioners, clinical psychologists, nutrition professionals, and licensed social workers may now provide telehealth. As part of COVID-19 emergency declarations, many governors have relaxed licensure and other state telehealth requirements so please contact your state board of medicine or department of health for up-to-the minute information.

Medicare will allow audio-only telephone E/M visits to be reported as telehealth, but they must be reported with the telephone E/M codes 99441-99443. Only two-way, real-time audio/visual E/M visits can be reported using codes 99201-99215.

In addition to traditional telehealth platforms, during the PHE CMS will allow apps like FaceTime and Skype as acceptable platforms. Telehealth, both audio-only and interactive audio and video, can be provided for any reason, regardless of whether the telehealth service is related to the diagnosis and treatment of health conditions related to COVID-19. Penalties will not be imposed on physicians using telehealth in the event of noncompliance with the regulatory requirements under the Health Insurance Portability and Accountability Act (HIPAA) during the PHE.

Standard Medicare copays and deductibles still apply to telemedicine visits, but there’s flexibility. During the coronavirus emergency, health providers will be allowed to waive or reduce cost-sharing* for telehealth visits. However, beneficiaries are still liable for cost-sharing for these services in instances where the practitioner does not waive cost-sharing. Practitioners should educate beneficiaries on any applicable cost-sharing.

*The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance, and copayments, or similar charges, but it doesn’t include premiums, balance billing amounts for non-network providers or the cost of non-covered services.

Source:  www.healthcare.gov/glossary/cost-sharing/  

Below is a listing of common CPT codes and Medicare coverage for telemedicine services.

Telehealth visits

Medicare telehealth services include office visits and consultations, among other services, provided by an eligible provider using an interactive two-way telecommunications system with real-time audio and video or audio-only telephone. Clinicians can report telehealth visits for both new and established patients on any real-time, non-public communication platform, such as FaceTime and Skype, and sets payment the same as in-person E/M visits during the COVID-19 PHE (see FAQs above).

E/M level selection can be based on medical decision making (MDM) or typical time listed in the CPT code description and CMS has temporarily removed any requirements regarding documentation of medical history and/or physical exam in the medical record during the COVID-19 crisis.

Select the appropriate code (99201-99215) and use the place of service (POS) that would have been reported had the service been furnished in person (e.g., 11-Office, 22-Hospital Outpatient, 23-Ambulatory Surgery Center). This will allow Medicare to pay for the service at the same rate that would have been paid if the service was furnished in person based on the provider’s location (i.e., facility or non-facility). Providers must also append telehealth modifier 95 to claim lines to identify that the service was furnished via telehealth. Providers who continue to use the general telehealth POS 02 code will be paid at the “facility” rate.

E/M Values and National Payments

Below are a list of codes and their physician work Medicare relative value units (RVUs) and approximate National office-based payment. E/M code levels must be assigned based on current Medicare E/M coding guidelines and rules.

*A list of all available codes for telehealth services can be found on the  CMS website .

Telephone evaluation and management service

CPT codes to describe telephone E/M are time-based. Effective March 1, 2020, payment for telephone E/M code 99441-99443 are equivalent to 99212-99214 and can be used for new or established patient during the PHE. Use modifier 95 and place of service (POS) where the visit would have taken place in person prior to the public health emergency (e.g., 11-Office, 22-Hospital Outpatient, 23-ASC). Check if your commercial payers pay for these services before reporting the codes for non-Medicare beneficiaries.

• CPT Code 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  [$46]
• CPT Code 99442  – 11-20 minutes of medical discussion  [$76]
• CPT Code 99443  – 21-30 minutes of medical discussion  [$110]

e-Consultations

e-Consultations are interprofessional telephone, internet or EHR provider-to-provider consultations. Code selection is time-based.

• CPT Code 99446  – Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review  [$18]
• CPT Code 99447  – 11-20 minutes of medical consultative discussion and review  [$37]
• CPT Code 99448  – 21-30 minutes of medical consultative discussion and review  [$56]
• CPT Code 99449  – 31 minutes or more of medical consultative discussion and review  [$74]
• CPT Code 99451  – Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 minutes or more of medical consultative time  [$37]
• CPT Code 99452  – Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes  [$37]

Note – For commercial payors, check with your individual payer’s policies directly for more information on coverage for telemedicine services.

CMS designed a CPT code selection grid located at the bottom of the  Medicare Telemedicine Health Care Provider Fact Sheet .

Additional resources

For the latest information on federal policy and payment changes related to telehealth in the midst of COVID-19, visit the  CMS Current Emergencies site .

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CPT Codes for Digital E/M Service

In the 2020 CPT codes set, CMS six released new codes to report online digital evaluation services or e-visits. The codes describe patient-initiated digital communications provided by physicians or other qualified health professionals, codes are 99421, 99422, and 99423. Three others who describe similar interactions when they involve a nonphysician health professional are 98970, 98971, and 98972. The new codes are spurred by digital health tools that are growing in popularity, such as patient portals. These tools enable patients and physicians to connect asynchronously and outside of face-to-face settings, making it easier for patients with transportation and scheduling barriers to get questions answered and receive care.

These six new codes will help physicians and others report a range of digital health services including electronic visits through secure patient portal messages. Digital evaluation and management services are not considered as telehealth services, so do not use POS 02 and modifier 95. CMS is requiring verbal consent for communication-based technology services (CBTS). This verbal consent is required annually and encompasses all CBTS, not a consent/service or consent for each provision of the service. 

For Qualified Health Professionals (QHP)

• CPT Code 99421: Online digital evaluation and management (E/M) service, for an established patient, for up to 7 days cumulative time during the 7 days; 5-10 minutes
• CPT Code 99422: 11-20 minutes
• CPT Code 99423: 21 or more minutes

Above mentioned codes are for use when E/M services are performed, of a type that would be done face-to-face, through a HIPAA compliant secure platform. These are for patient-initiated communications and may be billed by clinicians who may independently bill an E/M service. They may not be used for work done by clinical staff or for clinicians who do not have E/M services in their scope of practice.

Defining 7-day period: The seven-day period begins with the physician’s or other qualified health care professional’s (QHP) initial, personal review of the patient-generated inquiry. Physician’s or other QHP’s cumulative service time includes a review of the initial inquiry, review of patient records or data pertinent to assessment of the patient’s problem, personal physician or other QHP interaction with clinical staff focused on the patient’s problem, development of management plans, including a physician or other QHP generation of prescriptions or ordering of tests, and subsequent communication with the patient through online, telephone, email, or other digitally supported communication, which does not otherwise represent separately reported E/M service.

Coding Guidelines

• Codes are applicable only for established patients.
• As mentioned above, verbal consent is required by CMS. This verbal consent is required annually and encompasses all CBTS, not a consent/service or consent for each provision of the service.
• The patient initiates the service with an inquiry through the portal. 
• If the patient had an E/M service within the last seven days, these codes may not be used for that problem. If the inquiry is about a new problem (from the problem addressed at the E/M service in the past 7 days), these codes may be billed.
• If within seven days of the initiation of the online service a face-to-face E/M service occurs, then the time of the online service or decision-making complexity may be used to select the E/M service, but this service may not be billed.
• This may not be billed by surgeons during the global period.
• The digital service must be provided via a HIPAA compliant platform, such as an electronic health record portal, secure email, or other digital applications.

For Qualified Nonphysician Health Care Professionals

For online digital E/M services provided by a qualified nonphysician health care professional who may not report the physician or other qualified health care professional E/M services (e.g., speech-language pathologists, physical therapists, occupational therapists, social workers, dietitians), applicable codes are 98970, 98971, and 98972. CMS, however, said in the 2020 Final Rule that they would not recognize these codes, because they are defined by CPT as ‘evaluation and management services, and CMS reserves those words exclusively for physicians, advance practice nurse practitioners, and physician assistants. These codes have a status indicator of invalid in the Medicare fee schedule and don’t have RVUs assigned to them.

• CPT Code 98970: Qualified nonphysician health care professional online digital evaluation and management service, for an established patient, for up to 7 days, a cumulative time during the 7 days; 5-10 minutes. 
• CPT Code 98971: 11-20 minutes
• CPT Code 98972: 21 minutes or more

*CPT is a registered trademark of the American Medical Association (AMA) Copyright 2022

MedicalBillersandCoders (MBC) is a leading medical billing company providing complete revenue cycle services. Most providers make the mistake of billing digital E/M services as telehealth services, and end up with denied payments. We can help you in each process of outsourcing medical billing to ensure that you will receive accurate insurance reimbursements. To know more about our medical billing services, contact us at [email protected] / 888-357-3226

What are digital E/M services?

Digital E/M services are patient-initiated online evaluations provided by physicians or qualified health professionals through secure communication platforms, such as patient portals.

What CPT codes are used for digital E/M services by physicians?

The CPT codes for digital E/M services by physicians are 99421 (5-10 minutes), 99422 (11-20 minutes), and 99423 (21 minutes or more), applicable for established patients over a 7-day period.

Can digital E/M services be billed as telehealth services?

No, digital E/M services are not considered telehealth services and should not use POS 02 or modifier 95 when billed.

What is the role of verbal consent in digital E/M services?

CMS requires verbal consent from patients for communication-based technology services (CBTS). This consent is required annually and covers all digital E/M services.

What digital E/M codes are available for nonphysician health professionals?

Nonphysician health professionals use CPT codes 98970 (5-10 minutes), 98971 (11-20 minutes), and 98972 (21 minutes or more) for digital E/M services, but CMS does not recognize these codes for Medicare billing.

What are the requirements for billing digital E/M services?

Digital E/M services must be initiated by the patient, provided through a HIPAA-compliant platform, and are only for established patients.

Can digital E/M codes be billed during a global surgery period?

No, digital E/M services cannot be billed by surgeons during the global period.

What happens if a face-to-face E/M service occurs within seven days of a digital E/M service?

If a face-to-face E/M service occurs within seven days, the time spent on the digital E/M service can be considered for selecting the E/M code, but the digital service cannot be billed separately.

How can Medical Billers and Coders (MBC) assist with digital E/M services billing?

MBC can help healthcare providers avoid common billing mistakes, such as incorrectly billing digital E/M services as telehealth services, to ensure accurate reimbursements. Contact [email protected] or 888-357-3226 for more information.

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Meet the New CPT Codes to Report e-Visits in 2020

by Natalie Tornese | Posted: Feb 10, 2020 | Medical Coding

Digital E/M services allow US health systems to care for patients remotely. Several factors are fuelling the growth of remote patient monitoring and telemedicine, such as the aging population, patient demand, looming provider shortage, increase in chronic conditions, and policies to promote reimbursement for e-visits. Recognizing the expanding role of telemedicine in the U.S., the American Medical Association introduced six new e-visit CPT codes, which came into effect from Jan. 1, 2020. Providers can use physician billing services to accurately report these new codes for online digital evaluation services and get optimal reimbursement.

Six new CPT Codes for e-Visits

The 2020 Medicare Physician Fee Schedule (MPFS) describes e-Visits as non-face-to-face “patient-initiated digital communications that require a clinical decision that otherwise typically would have been provided in the office.” The six new codes for e-Visits are:

• 99421 , 99422 , and 99423 to report patient-initiated digital communication provided by a physician or other qualified healthcare professional
• 98970 , 98971 , and 98972 for digital communications with a non-physician healthcare professionals

“The new CPT codes will promote the integration of these home-based services that can be a significant part of a digital solution for expanding access to health care, preventing and managing chronic disease, and overcoming geographic and socioeconomic barriers to care,” said AMA President Patrice A. Harris, MD, MA.

Two New Codes for Self-measured Blood Pressure Monitoring (SMBP)

In addition to the above six codes, there are two new codes for SMBP in 2020.

High blood pressure or hypertension is a common problem that increases risk of heart attack and stroke risk. The goal of treatment is to bring the blood pressure level down to a healthy range (130/80 millimeters of mercury [mm Hg] or lower). SMBP can support this goal.

SMBP involves a patient’s regular use of personal blood pressure monitoring devices to assess and record blood pressure across different points in time outside of a clinical, community, or public setting, typically at home (www.cdc.gov). Monitoring blood pressure at home can help people newly diagnosed with high blood pressure or those struggling to reach their target. Harvard Health reported on research which showed that a period of home blood pressure monitoring – one week per month – was sufficient to guide people to better blood pressure control.

According to AMA Vice President of Health Outcomes Michael Rakotz, MD, SMBP provides clinically useful information to help physicians:

• more accurately diagnose and determine the need for treatment in people suspected of having uncontrolled high blood pressure based on routine office BP measurements
• compared to BPs obtained during a single office visit, SMBP provides more BPs over a longer period of time, which represents a more accurate picture of a patient’s BP
• Out-of-office measurements can better predict future cardiovascular risk than measurements taken in the office

In 2020, physician practices that educate patients to perform home blood-pressure monitoring can submit claims using two CPT codes associated with clinical services:

• 99473 Self-measured blood pressure using a device validated for clinical accuracy; patient education/training and device calibration
• 99474 Separate self-measurements of two readings one minute apart, twice daily over a 30-day period (minimum of 12 readings), collection of data reported by the patient and/or caregiver to the physician or other qualified health care professional, with report of average systolic and diastolic pressures and subsequent communication of a treatment plan to the patient

These codes will enable physicians to better diagnose and manage hypertension as well as help patients to play an active role in their care while at home.

Reporting 99421, 99422 and 99423 – Points to Note

• Codes 99421-99423 are for physicians and other qualified healthcare professionals (QHP)
• These codes can be used to report non-face-to-face patient initiated digital communications that require a clinical decision
• CPT code selection should be based on the time involved
• Communication between the patient and provider should be performed through HIPAA-compliant platforms (electronic health record portal or secure email)
• These codes should not be used for non evaluative electronic communication of test results

There are also guidelines on when not to bill online services when the patient is provided another service around the same time as online communication:

• Digital E/M followed by other E/M : If the patient initiates an online E/M service and then presents for a separately reported E/M within seven days, the online E/M work should be included in the separately reported E/M.
• E/M followed by online service : If the patient presents for an E/M and then initiates an online inquiry for the same problem or a related one within seven days, the online service should not be reported.
• Online E/M during post-op period : During the postoperative period, online inquiries related to a surgery should not be reported separately.

Hospitals and health systems are looking to expand care to the home or other non-traditional settings and work with patients and other care providers to improve outcomes and reduce costs. Providers who implement digital health care services can rely on medical billing outsourcing services to report the new codes correctly and get paid.

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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Best Guide to E-Visit Documentation, Coding, and Billing

Categories: Coding , CPT Codes , Medical Billing

Tags: billing code , coding , cpt code tips , e visits in healthcare , medical billing

The American Academy of Family Physicians (AAFP) encourages safe, secure online interactions between physicians and patients, such as electronic visits or “virtual e-visits.” In non-emergency situations, e-visits can substitute for office visits with primary care providers. It is a fast and easy online procedure for patients to receive a diagnosis and treatment plan.

This article will give you the best guide to e-visit documentation, coding, and billing.

What Should Providers Know About E-visits? 

An encounter must meet the following criteria to be considered an e-visit:

• The practice must have a well-established relationship with its patients.
• E-visits require patient consent and a communication request.
• The patient must initiate non-face-to-face electronic communication. For example, patient portal systems.
• Patients must not have seen an office visit to a physician or therapist for the same clinical concern in the past seven days.
• It is only possible to report e-visits every seven days.
• An e-visit is not the same as typical therapy sessions.

For e-visits, the following documentation requirements are needed:

• The main complaint with all evaluation and management services (E/M).
• The specifics of treatments, assessment of diagnoses or symptoms, evaluation, and conversation.
• An official patient consent record is backed up by a signature and captured in the clinical note. Moreover, e-visit software platforms accept scanned copies of signed consents. Some systems allow electronic signatures.
• The total time recorded over the seven days supporting the billable service.

List of Current Procedural Terminology (CPT) Codes That Require Providers to Follow Policies Set by Payers

The codes for online digital evaluation services (e-visits) used by doctors are complex. Below are the codes used:

Medicare uses the following HCPCS codes and descriptors for qualified non-physician professionals for its online digital evaluation service (e-visit):

Private payers and workers’ compensation are using the following online digital evaluation service (e-visit) CPT codes and descriptors:

Do’s and Don’ts in Billing E-Visits

When the following conditions are met, you can bill an e-visit:

• The provider establishes a relationship with the patient.
• Response time by the provider is longer than five minutes.
• A provider responds through the patient portal to a message initiated by the patient.
• A visit meets the 2021 E/M guidelines. 
• It has been seven days since the clinician last saw the patient.
• There is no global period for the same or similar condition for the patient.
• In this case, the provider is making a clinical decision that would normally be performed in the office (e.g., medication dose adjustment, ordering a test, or prescribing a new medication).
• A patient has consented to the e-visit and understands that he may be billed.
• For online digital E/M services, the service period includes all related work done within seven days by the reporting individual and other registered healthcare providers (RHPs) in the same group practice.
• The 7-day period begins when the reporting provider reviews the patient’s inquiry personally for the first time.
• A new/unrelated problem from the patient arises within seven days of the previous E/M visit for a different issue.

Do not bill an E-visit in the following situations:

• During the 7-day period, the provider may bill for other separately reported services (such as care management, INR monitoring, remote monitoring, etc.)
• The same or similar condition was billed to the patient for an e-visit within the past 7 days. 
• The patient inquires about a surgical procedure that happens during the surgery’s postoperative period (global).
• Providers are simply disseminating results, processing medication requests, or scheduling appointments (for billing, E/M services must be performed).
• A separate face-to-face E/M service (either in person or via telehealth) happens (included in the E/M) during the 7-day period of the e-visit.
• Besides clinical staff time, only provider time can be included.

The AAFP published an algorithm in response to the growing number of virtual visits. It was developed by James Dom Dera, MD, FAAFP, to determine which code should be used for virtual services.

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E/M office visit coding series: Tips for time-based coding

Series overview:

• How to code visits in one or two questions
• Tips for time-based coding 
• Problems are the coding key 
• Code the visit by just looking at your assessment and plan 

The 2021 E/M office visit coding changes allow physicians to code visits based solely on total time, which is defined as the entire time you spent caring for the patient on the date of the visit. It includes your time before the visit reviewing the chart, the actual face-to-face visit with the patient, and all the time you spend after the visit on documentation, reviewing studies, calling the patient or family, etc. — as long as you do it before midnight on the date of service. It does not include time you spend on other dates, time you spend doing procedures that are separately billed, or time your nurses or other staff spend.

For established patients, it may be helpful to remember what I call the “30/40 minute rule”: Level 4 visits start at 30 minutes, and level 5 visits start at 40 minutes. (For more time-based coding tips, see this previous “Getting Paid” post .)

Documentation tips

Documentation is important if you are going to base your coding on time. Rather than just writing “Total time spent was XX minutes,” it’s useful to explain what was included in the time, especially now that patients have access to your notes. They may not understand that the time you’ve listed includes more than just the face-to-face portion of the visit. Here’s an example of a well-explained note: “ Total time spent caring for the patient today was XX minutes. This includes time spent before the visit reviewing the chart, time spent during the visit, and time spent after the visit on documentation, etc.”

A little extra explanation may also be useful in case of an audit. For example, if you did a procedure during a visit and billed for it separately, you might want to add, “ Time excludes procedure time ” just to make sure there’s no confusion about that.

Take care with EHR time calculators

EHR time calculators that document the time a patient’s chart is open can be helpful if you’re using time for coding. But relying on them too much can cause problems. If you don’t remember to open the chart as soon as you enter the room and keep it open for the entire visit, it’s not going to accurately reflect the time you actually spent. If you can access the chart by smartphone as well as computer, make sure your EHR tracks time on both devices or, again, you will have an undercount.

Over-reliance on time calculators could also cause you to overstate your total time if your EHR double-counts time when the chart is open in your office and in the exam room simultaneously, or if it falsely counts time when the patient’s chart is tabbed but not opened.

Long visits (prolonged services)

Unfortunately, depending on the payer, there are currently different prolonged services codes, with different time ranges, for visits that exceed level 5 in total time. Medicare and some private insurance companies use G2212, which is for established patient visits of 69 minutes or more and new patient visits of 89 minutes or more. Other insurers use CPT code 99417, which is for established patient visits of 55 minutes or more and new patient visits of 75 minutes or more. With both codes, prolonged services are billed in 15-minute increments and pay 0.6 work Relative Value Units for each 15 minutes. Below is a chart you can quickly reference for time-based coding, including prolonged services.

— Keith W. Millette, MD, FAAFP, RPH

Posted on Oct. 31, 2022

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• Value-based payment

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Disclaimer: The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. All comments are moderated and will be removed if they violate our Terms of Use .

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