In the Sept. 4 issue of Neurology Today, Daniel B. Brown, Esq., a health care attorney based in Atlanta, reviewed legal, ethical, and health plan sources and reported on the propriety of physicians charging their patients for specific types of administrative items. In his response, he debunked many neurologists' assumptions that the Centers for Medicare and Medicaid Services (CMS) does not allow physicians to bill patients for failing to keep their appointments, and described related American Medical Association (AMA) policies, state billing statutes, and payer clauses.
In part two of the interview, Brown offers more detail about which direct charges are acceptable — and which practices are not — for billing for form completion, prior authorizations, excessive research time, after-hour routine refill requests, phone calls, and email transactions. His comments are excerpted below.
CAN WE BILL FOR THE FOUR NEW CPT CODES (99446-99449) FOR TELEPHONE/INTERNET ASSESSMENT WHEN THESE SERVICES ARE PROVIDED BY A CONSULTATIVE PHYSICIAN (DOCTOR-TO-DOCTOR)?
CPT codes 99446–99449 are for reporting inter-professional consultations via the Internet or telephone between a patient's treating physician (the requesting professional) and a physician with specific specialty expertise (the consultant). The consultations (or codes) may be used for complex and urgent situations when face-to-face patient contact with the consultant specialist is impractical, such as when there are access difficulties or other barriers. These evaluation and management (E&M) codes are time-based and may be reported only by the consulting specialist. Medicare does not currently reimburse services billed under CPT Codes 99446-99449. Neurologists who provide these types of consulting specialist services may consider contacting their commercial payers to discuss reimbursement under these codes.
WHAT ABOUT EMAIL (CPT CODES 98969 AND 99444) AND PHONE CALLS FROM PATIENTS (CPT CODES 98966-98968 OR 99441-99443), ESPECIALLY FOR AFTER-HOURS REQUESTS FOR ROUTINE PRESCRIPTION REFILLS?
Medicare's Claims Processing Manual makes clear that telephone call communications with patients are not covered as separate services. Medicare does not reimburse for these codes because these charges are considered to be included in the payment for face-to-face services. Although Medicare does not pay separately for physician or non-physician telephone or online conversations with patients (or their families), these conversations may be taken into account when the physician determines the level of E&M code to assign on the next claim for a face-to-face E&M visit—as long as proper documentation of the phone call is made and it is associated with the patient visit and not a separate issue. According to Medicare Manual Change Request 5895 (Transmittal 1423), documenting these services allows the physician to factor the phone call into the time or complexity calculations associated with the E&M levels. [It is important to note that when using time for calculations, 50 percent or more of that time must be face-to-face time spent in counseling or coordination of care.]
Accordingly, physicians should be careful when billing for these services to be sure that they are acceptable charges. Typically when insurance is paying for a visit or service, a prescription or phone/email follow-up will be considered part of the original covered service and separate charges for these “included” items are improper. On the other hand, if a patient calls in several months after their last visit and seeks medical advice on a completely unrelated issue apart from a past or future patient visit, the phone call could be considered an independent covered service.
IF MEDICARE WON'T COVER TELEPHONE OR INTERNET PATIENT CONSULTATIONS, CAN THE PHYSICIAN BILL THE MEDICARE BENEFICIARY DIRECTLY FOR THESE SERVICES?
Yes. A physician or non-physician practitioner may bill the beneficiary directly for telephone or Internet evaluation and management services. Although an advanced beneficiary notice (ABN) is not required, CMS strongly encourages providers to issue the voluntary ABN to their patients before billing for telephone or Internet consults so patients can make informed decisions in these situations. In addition, physicians should be sure that the same service is not recorded as any part of a subsequent Medicare E&M service, that the service components follow exactly the service descriptions in the applicable CPT code billed, and that the services are documented properly in the patient's medical record.
WHAT ARE THE RULES GOVERNING THE FORMS THAT PATIENTS BRING US TO FILL OUT—DISABILITY, RETURN TO WORK, ATHLETES' RETURN TO PLAY, GYM RELEASES, AND FAMILY MEDICAL LEAVE OF ABSENCE?
As is the case for copying records, office charges for pulling charts and filling out patient activity forms are routine and commonly accepted administrative charges. The ethical, statutory, and contractual rules governing these fees are the same as for no-show fees discussed in last month's column. For example, the AMA generally supports the ability of physicians to charge patients separate administrative fees for services like filling out forms for camp, school, or work in certain situations and when permitted by law or contract. One situation where separate charges for the delivery of forms may not be proper is when the charges appear as part of scheduled office visits. Performing these administrative tasks as part of the scheduled visit could be considered to be “double-billing” for visit services. This is in contrast to the no-show fees, which are by definition unrelated to any services provided regardless of circumstance.
AN INCREASING NUMBER OF NEUROLOGISTS, ESPECIALLY THOSE ON THE WEST COAST, SEEM TO BE GOING INTO CONCIERGE MEDICINE. CAN THEY CHARGE MEDICARE FOR SERVICES PROVIDED TO MEDICARE PATIENTS?
Yes, but only in limited circumstances. Physicians participating in concierge programs must not bill Medicare for Medicare-covered services. For example, after passage of the Affordable Care Act, Medicare began to cover routine preventative physical examinations. Concierge plans that offer Medicare beneficiaries physical exams as part of their menu of services now risk Medicare sanctions for double-billing their patients for these services. Concierge physicians should routinely review their contracts to determine if their service menu includes any Medicare-covered services.
SOME NEUROLOGISTS FEEL LIKE THEY ARE DROWNING IN PRIOR AUTHORIZATIONS FOR EQUIPMENT AND MEDS, BUT IS IT LEGAL TO BILL FOR THESE SERVICES?
In most cases, physicians cannot expect to get reimbursed for obtaining prior authorizations for their patient's treatments or medications. Medicare and private payers prohibit billing these charges as separate fees. The American Medical Association noted in a 2010 study that physicians spend an average of 20 hours per week on prior authorization. Medicare clearly believes that obtaining prior authorizations is an unreimbursed cost incurred by the physician and his staff.
WHY CAN'T WE CHARGE FOR THE TIME SPENT RESEARCHING THERAPIES FOR PATIENTS, JUST AS, FOR EXAMPLE, LAWYERS WOULD WHEN RESEARCHING A CASE?
Because lawyers and others negotiate their fees directly with their clients, it is easier for them to establish fees consistent with the cost and scope of the project and their [clients'] expectations of the results. Physicians do not have the luxury of dealing directly with their patients in fee negotiations. As a result, physicians find themselves accepting a flat fee per described encounter without consideration of the actual cost of performing that service. Unless the encounter code permits a separate charge for research or other service costs, a physician's invoicing the flat fee plus research would constitute improper double-billing.
Dr. Avitzur, an associate editor of Neurology Today and chair of the AAN Medical Economics & Management Committee, is a neurologist in private practice in Tarrytown, NY. She holds academic appointments at Yale University School of Medicine and New York Medical College.
Part 1 of the interview with Daniel Brown appeared in the Sept. 4 issue of Neurology Today. See “In Practice: Can I Charge for That? Missed Appointments, After-Hour Refills, and Other Tasks Outside the Traditional Billing Codes”: http://bit.ly/NT-InPractice
CHARGES RELATED TO SHARING MEDICAL RECORDS
As a general rule, federal and state law permits doctors to charge their patients reasonable copying fees. Charging patients separately for medical record copying and delivery would be improper only when the duplication service is part of a covered service that is already being reimbursed by a health insurance program.
The Health Insurance Portability and Accountability Act (HIPAA) permits doctors and other health care providers covered by HIPAA to charge “reasonable, cost-based fees” for providing copies of a patient's “protected health information” (PHI) to the patients or their personal representatives. Such charges may include the costs for: (1) copying, including the cost of supplies and labor of copying; (2) postage, if the individual has requested that the information be mailed; and (3) preparing an explanation or summary of the PHI, only if agreed to by the individual and as required if the individual requested a summary or explanation instead of records.
Almost every state has adopted laws authorizing physicians and other health care providers to charge their patients the reasonable cost of copying and delivering patient medical records. For example, Illinois Code of Civil Procedure 735 ILCS 5/8-2001(d) permits health care providers or facilities to charge patients for medical record copies at a sliding scale not to exceed $0.33 to $0.99 per paper page, depending on the number of copies. The cost is half the otherwise applicable paper records fee for the retrieval of records in electronic formats, but more if the records exist in microfilm or microfiche format. Illinois patients can also expect to pay a basic handling charge of $26.38 for processing the request, plus the actual postage or shipping charge, if any.
Note that HIPAA specifies that a covered entity can only charge “reasonable” fees based on actual costs for providing the medical records. If state fees are not cost-based, then they may be contrary to HIPAA and impermissible by federal regulation.
Note also that many states have adopted patient protection laws that prohibit physicians from refusing to deliver a patient's medical records, even if the patient owes the doctor's office for unpaid medical fees. For example, a Georgia law requires physicians or other providers to furnish patients with complete and current copies of the patient's medical record even if the patient owes fees to the doctor. The AMA considers it unethical for a doctor to withhold a patient's medical records due to an unpaid balance.