Reimbursement for Telephone Care

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Reimbursement for Telephone Care

Sanford M. Melzer, MD*, and Steven R. Poole, MD‡

ABBREVIATIONS. CPT, Current Procedural Terminology; E&M, evaluation and management (codes); HCFA, Health Care Financ-ing Administration; AAP, American Academy of Pediatrics; RVU, relative value unit.

I

n today’s health care environment, telephone care is an increasing component of pediatric prac-tice.1,2 _{Under pressure to limit office and}

emer-gency department utilization and with increasing expectations for access by working parents, pediatri-cians are finding themselves dispensing more and more advice over the telephone, both during and after office hours. Practice surveys have reported that telephone care accounts for at least 20% of all clinical care in a general pediatric practice and as much as 80% of after-hours pediatric care.3–5

Tele-phone care is not only an issue in primary care. Many pediatric subspecialists who care for children with chronic and special needs, such as diabetes or sei-zures, face extraordinary burdens in providing tele-phone-based disease management.6_{For others, such}

as pediatric infectious disease specialists, telephone consultation represents a significant part of their practice, and the issue of reimbursement for tele-phone care is of paramount importance.

The American Medical Association’s Current Pro-cedural Terminology (CPT-4) manual, the standard reference for coding medical encounters with pa-tients, categorizes telephone calls as case manage-ment services.7 _{Telephone calls by physicians for}

case management (eg, consultation, medical manage-ment, coordination of care) are categorized by com-plexity of medical decision making. Case manage-ment telephone calls involving simple, intermediate, or complex decision making are described by CPT codes 99371, 99372, and 99373, respectively (Table 1). If these calls lead to a visit, then they may be in-cluded in the preservice component of evaluation and management (E&M) codes.

Telephone calls are also included within “Care Plan Oversight Services,” which reflect physician work in the complex and multidisciplinary

manage-ment of patients being cared for by a home health agency, hospice, or nursing facility, and can be re-ported using CPT codes 99374, 99375, and 99377 to 99380.7_{These services, which are cumulative over a}

monthly period, are categorized by approximate physician time spent. This is in contrast to other E&M codes, which are based on history, physical examination, and medical decision making and for which time is not a component (unless counseling exceeds 50%).

Reporting these CPT codes for telephone care re-quires that the physician 1) ensures appropriate doc-umentation to support the level of service and 2) submits the charge on a Health Care Financing Ad-ministration (HCFA) 1500 professional billing form. Unlike other E&M codes for which there are fairly specific guidelines for the various code descriptors, such as history, examination, and medical decision, the CPT manual provides little specific guidance on the criteria to select among CPT codes 99371 through 99373. A recent informal poll of the American Acad-emy of Pediatrics (AAP) Committee on Coding and Reimbursement members regarding standard tem-plates for coding telephone calls suggested that such templates are not in common use (S. Melzer, per-sonal communication, August 2001).

For all telephone codes, we suggest that physicians document the time spent in the encounter. This is especially important for CPT codes 99374 to 99380, which are reported based on time. Although the CPT manual does not specify “typical times” for tele-phone calls described by CPT codes 99371 to 99373, the typical times for the “established patient visit” codes 99211, 99212, and 99213 (which have similar relative value units [RVU]) are 5, 10, and 15 minutes, respectively. Physicians should also include in their documentation the type of service provided (eg, con-sultation or medical management, initiate or adjust therapy, report results or coordinate care with other health care professionals) and state whether the call pertains to a new problem. Telephone calls to pro-vide advice, initiate therapy, or coordinate care for a new problem may be coded using CPT 99372. Phy-sicians who report CPT code 99373 (complex or lengthy telephone calls) should include additional documentation to support the complexity of the care, such as the patient’s severity of illness or number of other health care professionals involved in the pa-tient’s care.

The decision to report telephone care codes to health plans requires that physicians develop and implement consistent policies regarding billing indi-vidual patients for these services in the event that the From the *Children’s Hospital and Regional Medical Center and the

Uni-versity of Washington School of Medicine, Seattle, Washington; and ‡Uni-versity of Colorado School of Medicine and Children’s Hospital and Re-gional Medical Center, Denver, Colorado.

Received for publication Apr 9, 2001; accepted Sep 25, 2001.

Reprint requests to (S.M.M.) Children’s Hospital and Regional Medical Center and the University of Washington School of Medicine, 4800 Sand Point Way NE, Box 5371 (MS: CH-41), Seattle, WA 98105-0371. E-mail: smelze@chmc.org

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plan does not pay. The AAP Coding for Pediatrics 2001 manual recommends that to ensure that all patients being charged for telephone calls are treated equally and fairly, “the physician must be willing to 1) bill the patient for the service if the code is rejected by the insurance carrier, and 2) charge a copayment for the service.”8

Telephone care requires a high level of assessment and judgment, entails practice expenses and mal-practice risks, and provides a substitute for costly office and/or emergency department visits. Despite these characteristics, telephone care is frequently not reimbursed by most health plans.6,9 –15 _{There are a}

number of reasons that telephone care reimburse-ment is lacking. First, HCFA, by declining to assign a work RVU value to the telephone care codes, has indirectly sent a message that telephone care is not a procedure that generates sufficient value to justify reimbursement. Second, even when telephone ser-vices are reported, many plans contend that tele-phone care is a part of the normal pre- and postvisit office E&M codes and deny payment on the basis that this care is already included in the RVUs sur-veyed and assigned for those services. Third, a sub-stantial portion of pediatric telephone care is pro-vided by nurses, and none of the telephone codes TABLE 1. CPT Codes and RVUs for Telephone Calls

CPT Code Description RVUs

Work Value

Practice Expense

Malpractice Expense

Total

99371 Telephone call by a physician to a patient or for consultation or medical management or for coordinating medical management with other health care professions (ie, nurses, therapists, social workers, nutritionists, physicians, pharmacists); simple or brief (eg, to report on test and/or laboratory results, to clarify or alter previous instructions, to integrate new information from other health professional into the medical treatment plan, or to adjust therapy).

0.19 0.14 0.01 0.34

99372 Intermediate (ie, to provide advice to an established patient on a new problem, to initiate therapy that can be handled by telephone, to discuss test results in detail, to coordinate medical management of a new problem in an established patient, to discuss and evaluate new information and details, or to initiate a new plan of care).

0.49 0.35 0.02 0.86

99373 Complex or lengthy (eg, lengthy counseling session with anxious or distraught patient, detailed or prolonged discussion with family members regarding seriously ill patient, lengthy communication necessary to coordinate complex services of several different health professionals working on different aspects of the total patient care plan).

0.98 0.71 0.03 1.72

99374 Physician supervision of a patient under care of home health agency (patient not present) in home, domiciliary or equivalent environment (eg, Alzheimer’s facility) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with other health care professionals involved in patient’s care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15–29 minutes.

1.10 0.47 0.04 1.61

99375 Thirty (30) minutes or more. 0.00 0.00 0.00 0.00

99377 Physician supervision of a hospice patient (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status,review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with other health care professionals and other nonphysician

professionals involved in patient’s care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15–29 minutes.

1.10 0.47 0.04 1.61

99379 Physician supervision of a nursing facility patient (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with other health care professionals and other nonphysician

professionals involved in patient’s care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15–29 minutes.

1.10 0.47 0.03 1.60

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apply to nonphysician providers of triage and/or advice. Finally, many pediatricians simply do not bother to submit claims for these services because the anticipated low reimbursement does not justify the time or expense in meeting the documentation and/or costs of billing and collection services.

Physician experience with payment for telephone care is limited. Certain Medicare plans pay for tele-phone calls during which care plans are arranged. Although most Medicaid programs do not reimburse providers for telephone care, some Medicaid man-aged care plans include telephone triage as one of their covered services under capitation. The collec-tion rate from commercial insurers for charges for telephone care has been reported to be in the range of 50% to 60%.6_{A recent study of reimbursement for}

codes 99371 to 99373, for which care of childhood diabetes was provided by physicians or nurses via telephone, showed that in Texas, Medicaid did not reimburse for telephone management of complex problems. Fourteen of 18 insurance companies reim-bursed at 26% of charges, and parents paid copays at 54%.6 _{In that study, the authors reported that the}

collection rate for diabetic telephone care in a pri-marily insured population was 33%.

Reimbursement for clinical telephone care is sup-ported by the majority of pediatricians, who argue that the physician work component of telephone care shares all of the characteristics of in-office care, ex-cept for the hands-on physical examination, and that telephone care also entails medical liability and other practice costs.9 –15 _{Studies demonstrating the}

cost-effectiveness and safety of telephone care support the notion that encouraging telephone care by reim-bursing physicians for the service may, in fact, de-crease pediatric health care costs.5,16,17 _{Those who}

are concerned with the liability issues argue that the documentation requirements associated with reim-bursement for telephone care may encourage physi-cians to provide higher quality telephone care and documentation. Other physicians, reluctant to charge for telephone care, have raised concerns that billing for telephone care may 1) deter poor families from calling with serious problems, 2) create a negative physician image, 3) tempt physicians to overuse (or abuse) charging, and 4) cause patients to switch their care to practices that do not charge for telephone care.9

Among pediatricians who support reimbursement for telephone services, there is a wide range of opin-ion regarding the financial value of telephone care. A national survey of after-hours telephone triage and advice call centers sponsored by children’s hospitals revealed that the mean charge per call was $3.50, and the second most common charge per call was $5.90.18

A survey of Albany physicians determined that most pediatricians believe that physician calls should be reimbursed in the range of $2.00 to $2.50 per minute.2

A fee survey of 1619 pediatricians conducted by the AAP indicated physician charges of $20 for CPT telephone code 99371, $30 for CPT code 99372, and $50 for CPT code 99373.19 _{Using the 2001 HCFA}

conversion factor of $38.26, the equivalent (nonfacil-ity total) RVUs for these activities would be

approx-imately 0.52, 0.79, and 1.30. This compares to the RVUs for the commonly used “established patient visit” codes 99211, 99212, and 99213, respectively.

Few data describe the perspective of families re-garding payment for telephone care. Patient satisfac-tion with telephone triage and advice programs is generally very high.5,20_{However, many parents also}

believe that they should not have to pay for this service. In one customer service survey in Seattle, only 35% of parents who use an after-hours triage service indicated that they would be willing to pay for telephone care, although among this group the mean price that they would be willing to pay was $10 per call (S. Melzer, personal communication, March 1999). In a survey from Albany, New York, parents indicated that they were willing to pay $25 to pre-vent a visit to an emergency department or perhaps to the office.2

In summary, the issue of reimbursement for tele-phone care represents a significant challenge to pe-diatricians. Faced with the task of meeting the expec-tations of parents and health plans, physicians find themselves compelled to manage complex medical problems over the telephone, dedicate practice re-sources, and expose themselves to liability risk with little assurances that these efforts will be compen-sated. Given the multitude of financial pressures that pediatricians and the health care system at large face, what is a reasonable way to proceed in resolving this issue?

At a local level, pediatricians are encouraged to work together to gather utilization data and engage the local health plans in discussions regarding this issue. One approach may be for pediatricians who have not billed for telephone services to begin this practice by regularly documenting and billing for telephone care. This will raise awareness among pay-ers and possibly help set the stage for negotiations for reimbursement for this important component of pediatric care.

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gather and pool utilization data. This data will assist AAP committees and sections as they evaluate and implement strategies to improve reimbursement for telephone care.

REFERENCES

1. Poole SR, Glade G. Cost-efficient telephone care during pediatric office hours.Pediatr Ann.2001;50:256 –267

2. Sorum PC, Mallick R. Physicians’ opinions on compensation for tele-phone calls.Pediatrics. 1998;99(4). Available at: http://www.pediatrics. org/cgi/content/full/99/4/e3

3. Curtis P, Talbot A. The telephone in primary care.J Commun Health.

1981;6:194 –203

4. Robert Wood Johnson Foundation.Medical Practice in the United States. Princeton, NJ: Robert Wood Johnson Foundation; 1981

5. Poole SR, Schmitt BD. After-hours telephone coverage: the application of an area-wide telephone triage and advice system for pediatric prac-tices.Pediatrics.1993;92:670 – 679

6. Kirkland J, Copeland K. Telephone charges and payments in a diabetes clinic.Pediatrics.1998;101(4). Available at: http://www.pediatrics.org./ cgi/content/full/101/4/e2

7. American Medical Association.Physicians’ Current Procedural Terminol-ogy(CPT). Chicago, IL: American Medical Association; 2000 8. Bradley J, ed.Coding for Pediatrics. A Manual for Pediatric Documentation

and Reimbursement. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2001

9. Braithwaite SS, Unferth NO. Phone fees: a justification of physician

charges.J Clin Ethics.1993;4:219 –224

10. Churgin PG. Compensating physicians for telephone calls [letter].

JAMA.1995;274:216,217

11. Health H. Compensating physicians for telephone calls [letter].JAMA. 1995;274:216

12. Radecki S. Compensating physicians for telephone calls [letter].JAMA.

1995;274:216 –217

13. Nelson AR. Compensating physicians for telephone calls [letter].JAMA

1995;274:217

14. Sorum PC. Compensating physicians for telephone calls [letter].JAMA.

1995;274:217–218

15. Metzl K. Telephone advice: to charge or not to charge, that is the question.Pediatrics.1998;102:969

16. Kempe A, Dempsey C, Poole SR. Appropriateness of urgent referrals by nurses using a computerized pediatric telephone triage system.Arch Pediatr Adolesc Med. 2000;153:355–360

17. Kempe A, Dempsey C, Hegarty T, Frei N, Chandramouli V, Poole SR. Reducing after-hours referrals by an after-hours call center with second-level physician triage.J Ambulatory Pediatr. 1968;73:271–279

18. Melzer S, Poole SR. Automated pediatric telephone triage and advice programs at children’s hospitals: operating characteristics, financial performance and perceived value.Arch Pediatr Adolesc Med. 1999;153: 858 – 863

19. Agrawal B, Tomany S.Pediatric Service Utilization, Fees, and Managed Care Arrangements. 1999 Report Based on 1997 Data.Elk Grove Village, IL: American Academy of Pediatrics; 1999

20. Strasser PH, Levy JC, Lamb GA, Rosekrans J. Controlled clinical trial of pediatric telephone protocols.Pediatrics.1979;64:553–557

BRITAIN: NO BAN ON HITTING CHILDREN

“The government said it would not introduce legislation making it illegal for parents to hit children in England and Wales even though Scotland has already announced plans to propose such a law. ‘I am not convinced that banning smack-ing actually helps us to be better parents,’ said Health Minister Jacqui Smith. Mary Marsh, director of the National Society for the Prevention of Cruelty to Children, said that the government was ignoring the views of child welfare advocates and that ’children should enjoy the same legal protection from being hit as that afforded to adults.’”

Lyall S.New York Times. November 9, 2001

Noted by JFL, MD

ARTICLES 293

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DOI: 10.1542/peds.109.2.290

2002;109;290

Pediatrics

Sanford M. Melzer and Steven R. Poole

Reimbursement for Telephone Care

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Sanford M. Melzer and Steven R. Poole

Reimbursement for Telephone Care

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