Telephone E&M Services: When to “Make the Call” for Records Requests
Telephone E&M services, specifically CPT (Current Procedural Terminology) 99441-99443, were infrequently utilized prior to the pandemic. After a thorough analysis, Codoxo noticed increased utilization and inappropriate billing scenarios in our partner’s data related to all lines of business. Although telephone E&M services were not included in the Public Health Emergency code set for temporary use, these services are covered by Medicare, and depending on your policies may be covered through your health plan for other lines of business. Of interest, telephone E&M services are not listed as an NCCI edit with E&M services.
Telephone Evaluation & Management Service Codes
| CPT Code | Time Element |
|---|---|
| 99441 | 5-10 minutes of medical discussion |
| 99442 | 11-20 minutes of medical discussion |
| 99443 | 21-30 minutes of medical discussion |
What are the criteria for use of telephone E&M services?
- Only billable by physicians or qualified health practitioners, such as a nurse practitioner or physician assistant
- Requires documentation as to what was discussed and the duration of the call (start-stop time)
- Only applies to established patients
- Does not require modifier –93 to designate the audio-only aspect of telehealth
- Cannot be used as a follow-up from an E&M service provided within the previous seven days
- Cannot result in an E&M service within the next 24 hours or the soonest available appointment
What telehealth scenarios might your plan find within your claims traffic?
Scenario 1: Parent/son telephone discussion with a physician regarding parent’s memory loss
A call is placed to the physician who saw the parent with the son in the office 10-days prior. A 15-minute discussion between the physician and the parent/son occurred with the parent’s overall condition reported as stable and memory loss as consistent for the age. The physician billed CPT 99442 appropriately.
Scenario 2: Parent/infant discussion with a physician regarding an infant’s high temperature
A new mother calls the pediatrician’s office concerning her infant, who has a fever of 101 and was seen 3 weeks ago for their first well-check visit. The mother talks with a nurse practitioner who instructs the mother on what steps to take to lower the infant’s temperature and recommends that the mother returns to the office within the next 24 hours. The parent and infant visit the pediatrician’s office the same afternoon at which time a physician assistant learns the infant has only had 2 diaper changes all day, which could mean the baby is dehydrated, and recommends the mother and infant visit the emergency department for further evaluation. The pediatrician’s office submits a claim for CPT 99214 for the office visit and CPT 99442 for the telephone E&M service, which is inappropriate.
Scenario 3: Outlier claim submissions for telephone E&M services
In response to social distancing requirements during the pandemic, your health plan adds telephone E&M services to all benefit packages and notifies the provider network regarding the coverage enhancement. Your plan receives a hotline complaint from a member about their EOB (Explanation of Benefits) and multiple claims for CPT 99443 over a two-week period. The customer service representative advised the member that telephone E&M services are included with their benefits package and provides a limited description of the time-based service. The member confirms they spoke with a physician’s assistant a few times a week; however, those calls were only 5 to 10 minutes long. The customer service representative documented the complaint and the potential inconsistency with the billed code versus time spent for the telephone E&M service.
In response to the complaint, a utilization management team member reviewed the claims traffic from the provider for the past 6-months and noticed that all telephone E&M services were billed with CPT 99443 and numerous patients were billed for 2 or more services per week. In some instances, this provider submitted 40+ claims for CPT 99443 for one patient and the overall procedure-to-patient ratio was 9:1. The provider’s claims exclusive billing of CPT 99443 suggested upcoding with a high frequency of services that may be unsupported. The utilization team member notified the health plan’s SIU (Special Investigations Unit) about the provider’s outlier claim submissions, which appear inappropriate based on the time element and procedure-to-patient ratio.
How can Codoxo’s Forensic Platform Query tool assist your health plan with identifying inappropriate telephone E&M services?
Regarding Scenario 2, the Professional Claims query tool can quickly find providers submitting telephone E&M services with office-based E&M services on the same date of service using the following criteria:
– Choose Professional, Claims as the query options, and then select:
- Procedure Code = Custom Editor [Copy and paste the following advanced query criteria]: (99441 OR 99442 OR 99443) AND (99202 OR 99203 OR 99204 OR 99205 OR 99212 OR 99213 OR 99214 OR 99215)
- Provider Payment Received = Within this Range [Minimum Amount = 1]
- Click Search to see results
- Click Show Chart to find the providers with the highest volume of claims or payments for Scenario 2
Regarding Scenario 3, Codoxo customers can utilize the Professional Aggregates query tool to easily identify providers with a volume of exclusive utilization of telephone E&M services or with high procedure-to-patient ratios for telephone E&M services through the following steps:
Choose Professional, Aggregates, Rendering, and Procedure as the query options, and then select:
- Procedure Code = Within this Range [99441 – 99443]
- Matching Claims = Within this Range [Minimum = 200]
- Patients = Within this Range [Minimum = 25]
- Provider Payment Received = Within this Range [Minimum Amount = 1]
- Click Search to see results
***The criteria for Matching Claims and Patients are suggested values; your plan’s claim volume for telephone E&M services may vary and these values should be adjusted accordingly***
As always, please verify your plan’s policy and guidance around telephone E&M services before initiating a review of the claims traffic and submitting a request for records from your network providers.
If you are interested in learning more about Codoxo’s forensic AI platform or would like to speak to Codoxo team member, contact us via info@codoxo.com.
