99421, '22 '23 : Online Brief Evaluation (eg Email or via EHR Portal) ($15-47)

 99421 - OL DIG E/M SVC 5-10 MIN

 

RUC Rationale

In September 2018, the CPT Editorial Panel deleted two codes and replaced them with six new non-face-to face codes to describe patient-initiated digital communications that require a clinical decision that otherwise typically would have been provided in the office. 

Three codes describe the physician e-visit (99421, 99422 and 99423) ($15, $30, $47) and three codes describe the qualified nonphysician health care professional e-visit (98970, 98971 and 98972). 

99421 Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes 

The RUC reviewed the survey results from 92 physicians and determined that the survey 25th percentile work RVU of 0.25 appropriately accounts for the work required to perform this service. The RUC recommends 8 minutes intra-service time. The RUC noted that this service includes only intra-service time as this service starts with the physician opening up the electronic communication, which differs from the top key reference code 99441 Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion (work RVU = 0.25 and 8 minutes intra-service time, 13 minutes total time), where the physician may get a voicemail and may have an opportunity to review the medical record before engaging in the call. The e-visit is the documentation of the visit itself, the e-mail response. 

99441

$56

But not paid by CMS

Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

The RUC compared the surveyed code to the top key reference code 99441 and noted that these services require the same physician work and intra-service time to perform. 

However, 99421 is more intense than 99441 because the physician response is documented in writing. [only]

There is a higher risk and challenge within the written response, as the physician or patient may misinterpret something within the communication. Whereas, with a telephone call, any misinterpretations would be clarified with immediate feedback. Additionally, 99421 is more intense because the physician may review multiple images, some of which may be hard to decipher and the physician will need to engage in multiple communications over seven days that adds to the complexity of this service. 

For additional support, the RUC referenced MPC codes 99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes (work RVU = 0.24 and 7 minutes intra-service/total time) and 92568 Acoustic reflex testing, threshold (work RVU = 0.29 and 8 minutes intra-service time), which demonstrates the appropriate relativity among similar services. The RUC recommends a work RVU of 0.25 for CPT code 99421. 

99422 

Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes 

The RUC reviewed the survey results from 96 physicians and determined that the survey 25th percentile work RVU of 0.50 appropriately accounts for the work required to perform this service. The RUC recommends 15 minutes intra-service time. The RUC compared the surveyed code to the top key reference code 99442 Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion (work RVU = 0.50 and 15 minutes intra-service time, 21 minutes total time) and noted that these services require the same physician work and intra-service time to perform. However, 99422 is more intense than 99442 because the physician response is documented in writing with higher risk and challenges with multiple communications, not a verbal response with immediate clarifications as detailed in the rationale for CPT code 99421. For additional support, the RUC referenced MPC code 99212 Office or other outpatient visit for the evaluation and management of an established patient, (work RVU = 0.48 and 10 minutes intra-service, 16 minutes total time), which demonstrates the appropriate relativity among similar services. The RUC recommends a work RVU of 0.50 for CPT code 99422.

 99423 Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes 

The RUC reviewed the survey results from 95 physicians and determined that the survey 25th percentile work RVU of 0.80 appropriately accounts for the work required to perform this service. The RUC recommends 25 minutes intra-service time. The RUC compared the surveyed code to the second top key reference code 99443 Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion (work RVU = 0.75 and 20 minutes intra-service time, 31 minutes total time) and noted that code 99423 requires slightly more physician work to perform because it describes 21 minutes or more, emphasis on more because the service will likely require more than 21 minutes, potentially much more. Whereas, CPT code 99443 is up to 30 minutes. Additionally, the typical patient receiving 99423 has problems and concerns greater than the average patient. The RUC agreed that 99423 is more intense than 99443 because the physician response is documented in writing with higher risk and challenges with multiple communications, not a verbal response with immediate clarifications as detailed in the rationale for CPT code 99421. For additional support, the RUC referenced MPC codes 99231 Subsequent hospital care, per day, for the evaluation and management of a patient… (work RVU = 0.76 and 10 minutes intra-service, 20 minutes total time) and 99213 Office or other outpatient visit for the evaluation and management of an established patient… (work RVU = 0.97 and 15 minutes intra-service, 23 minutes total time), which demonstrates the appropriate relativity among similar services. The RUC recommends a work RVU of 0.80 for CPT code 99423. Practice Expense The RUC recommends the direct practice expense inputs as submitted by the specialty society. New Technology/New Services The RUC recommends that CPT codes 99421, 99422 and 99423 be placed on the New Technology list and be re-reviewed by the RUC in three years to ensure correct valuation and utilization assumptions.