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Phone (audio-only) visits have been instrumental in caring for patients during the pandemic.
We take a look at how they’ve been implemented in various forms and where they might be going now that the public health emergency is coming to an end.
I Remember It Like It Was...
Life as we know it changed dramatically in March 2020. COVID-19 had reached our shores and was spreading like wildfire. The world as we knew it was forever changed.
Horror stories were rolling in from the toll COVID was taking in Italy. Toilet paper, sanitizing wipes, hand sanitizer, and PPE were nigh impossible to find. Doomsday preppers’ time to shine had come.
The only things that were in high supply were uncertainty, unease, and the word “unprecedented.”
Medicine as we knew it was also forever changed. We had to figure out how to still care for patients. And we did so, often to the detriment of our own wellbeing, not knowing if we would test positive for the dreaded virus, or, worse yet, bring it home to our loved ones.
That One Time CMS Was Ahead of the Curve
Thankfully, to help us find new ways to care for our patients, CMS eased restrictions on and even expanded telehealth as part of the Public Health Emergency (PHE).
In doing so CMS allowed for audio-visual (a.k.a. video, virtual, etc.) visits as well as audio-only (a.k.a phone) visits. And the commercial payers followed suit.
More importantly, CMS made the decision to reimburse these equivalently to regular E/M office visits. Again, the commercial payers followed suit. This was critical to helping practices stay afloat and pivot to the new normal.
I know I would have been significantly limited in caring for my patients especially in the early months of the pandemic without the expanded telehealth modalities.
CMS tends to be reactionary, and not in a speedy way—-in fact, usually in the slowest way possible.
So their rapid action and shift on telehealth was a welcomed change. Some might even say…unprecedented. #sorrynotsorry
A Tale of Two Billing Schema for Phone Visits
Most of the major commercial payers adopted policies to allow the regular E/M LOS codes to be applied to phone visits. So physicians can bill them the same as office visits, either on medical decision making or time.
Nice, clean, and simple.
However, CMS themselves and Aetna (there may be more, but these are the ones of which I’m aware) chose a more complicated approach.
Of course they did.
(Hey, CMS had to harken back to their roots, or we’d mistake them for a nimble start-up.)
CMS’ way of operationalizing phone visit and office visit parity works as follows:
1) They use the original audio-only LOS codes 99441-99443
- 99441: 5-10 minutes
- 99442: 11-20 minutes
- 99443: 21-30 minutes
2) These are the timeframes used that are then crosswalked to the office visit LOS codes 99212-99214
- 99441 → 99212
- 99442 → 99213
- 99443 → 99214
Key Things to Note about the Second Schema
1) There is no ability to hit a 99215 with CMS and Aetna via a phone visit.
2) They use the audio-only visit times to code, which means the following two points are true.
3) A 5 minute visit is a 99212. As an office visit, for an established patient this would be a 99211, and for a new patient would not be billable at all on time since 99201 has been retired.
4) Similarly, you can hit a 99213 and 99214 with shorter visit times compared to if the patient was seeing you in person.
So overall, physicians who see patients faster can legally over-inflate their billing with CMS and Aetna given their decision to crosswalk the codes over.
Conversely, those who spend more than 30 minutes on phone visits are penalized with this crosswalking schema.
Video Visits Codified…
In 2022, CMS made permanent the decision for audio-visual (video) visits to be billed equivalently as office visits at all levels for both new and established patients.
Yay!
…Phone Visits, Not So Much
Ah, damn.
Prior to the PHE, CMS only permitted audio-only visits for behavioral health in very limited circumstances, typically in underserved, rural areas. Reimbursement was tricky and often contested.
Additionally, there were telephone codes to be used in other circumstances, but their reimbursement was pittance and often made them a non-starter.
And even now, CMS has chosen not to codify audio-only visits as being on par with office visits.
Payers and businesses are lobbying Congress and CMS strongly to prevent such codification. From the payers’ perspective, phone visits represent a lowered barrier of health care access, which means more potential costs to them.
Paying for care, I mean. Right?
And naturally, these for-profit enterprises will pass those costs on down to the businesses who offer the insurance products to their employees and their families, so businesses are not fans either.
Meanwhile, physicians and patients are advocating fiercely to preserve as-is audio-only visits seeing how they’ve both benefited tremendously.
Now I understand payers not wanting to cover the CMS/Aetna crosswalking schema since it’s easier to hit the more commonly billed 99213 and 99214 visits.
But what about the other schema that is the same as video visits?
Phone Visits Days Numbered?
The PHE expires at the end of day on May 11, 2023. That means the emergency telehealth provisions will disappear unless Congress or CMS takes other action.
Congress has passed legislation previously that extends all PHE measures after the PHE expires for an additional 151 days. This means phone visits as we now know them can be billed as is through October 9, 2023.
I fully expect that we’ll hear more about the future of phone visits this summer (CMS tends to release their proposed changes and updates in July).
Oh, and That Other Important Thing
One of the unique telehealth provisions implemented during the PHE was allowing physicians and others to render the services from their homes without reporting their home addresses on their Medicare enrollment, and instead continuing to bill from their currently enrolled locations (e.g., their clinics).
This waiver continues through December 31, 2023.
After that, it’s anyone’s guess.
Well, not quite.
There is precedent for using your office address if that’s the location where you usually practice. However, if you’re employed and moved 100% of your practice to telehealth from your home, then in 2024 you may need to report your home address to Medicare as the location the service was rendered, which seems disturbing.
Again, I expect we’ll hear more on this matter in the upcoming months.
If you’re on my email list, I’ll keep you apprised as I learn more.
Also, if I see any specific advocacy efforts to support ongoing phone visit billing parity, then I’ll share them with you. (I had previously shared ACP’s efforts to gather qualitative reports about the benefits of phone visits to share with Congress).
How important are phone visits to your practice? Were you aware of the discrepancy in how they’re handled by the various payers? Any other thoughts on them? Let me know in the comments section below.
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