New Medicare coverage for interprofessional consults and virtual check-ins

Beginning Jan. 1, Medicare will pay separately for interprofessional consults. The new CPT codes are 99451–99452 and 99446–99449 and payment ranges from about $18 to about $73 dollars depending on the time involved. Interprofessional services provided under these codes can only be billed by qualified Medicare practitioners, and the patient’s verbal consent must be noted in the patient’s medical record given that these services will be performed when the beneficiary is not present, and cost-sharing will apply.

New CPT guidance imposes additional criteria for reporting these services. Briefly:

  • If the consultation leads to a transfer of care or other face-to-face services within the next 14 days (or soonest available appointment date of the consultant) the codes should not be reported.
  • More than 50% of the time must be devoted to medical consultative verbal or internet discussion (and not a review of data).
  • If more than one communication or contact is needed to complete the consult, the service should be reported only once with a single code.
  • The codes should not be reported more than once within a seven-day interval.
  • Codes 99446–99449 conclude with a verbal opinion and written report by the consultant; 99451 concludes with only a written report.
  • Communications of less than five minutes should not be reported.
  • The codes should only be reported by the consultative physician; the treating/requesting physician can bill CPT code 99452 if the service takes 30 minutes or longer.

The availability of reimbursement for these consultations should promote better communication between allergists and primary care physicians and enhance patient care.

Virtual check-ins for established patients

The Centers for Medicare and Medicaid Services (CMS) recently proposed to pay for brief, non-face-to-face “virtual check-ins” to assess whether the patient’s condition necessitates an office visit. The proposed rule was finalized, and CMS created coding for a brief consult (five to 10 minutes) by telephone or other technology (in real time), provided by a qualified health care professional to an established patient. Only those providers that can bill evaluation and management (E/M) services (e.g., physicians, advanced practice nurses, physician assistants) may provide and bill this service. The national payment amount is $14.78 (non-facility) and $13.33 (facility).

However, several conditions apply. The check-in cannot originate from a related E/M service provided within the previous seven days and cannot lead to an E/M service or procedure within the next 24 hours, or whenever the soonest available appointment is. If the check-in occurs within this time frame, it would then be bundled into the pre- or post-visit E/M service and is not separately billable. CMS noted that it would monitor these services to determine if the timeframes should be changed under future rules. These services may be provided over the phone in addition to video chats.

Verbal consent from Medicare beneficiaries is also required to bill for this technology-based service. While CMS acknowledges that requiring verbal consent may pose potential administrative burdens on practices, CMS finalized this requirement to avoid beneficiaries being responsible for unexpected and unwanted copays for such services. CMS has also limited the availability of virtual check-ins to established patients.

Advocacy Issue: 
Billing, Coding & Payments