99446-9 - Codes for Physician to Physician EHR Evaluation and Consult; RUC

Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional.  This is a representative vignette (99446-94449).

RUC Rationale

In June 2010, the CPT Editorial Panel created the Telephone Consultative Services Workgroup to address a proposal to create codes describing telephone/internet consultative services. 

The workgroup was charged with the following: Clarify use by non-physicians; Review the appropriateness of time increments for physician to patient calls; Clarify the typical patient/service descriptions based upon literature supplied; Consider appropriate use of term “consultation”; and Consider time interval for non-reporting as being distinct from a patient call (ie, if a face to face service occurs the next week or if co-management is in progress and the patient is seen every month, but more than 7 days previously, is the service reported). 

In May 2012, the CPT Editorial Panel approved a new Evaluation and Management subsection, guidelines and four codes to describe and report telephone/internet consultative services. An interprofessional telephone/internet consultation is an assessment and management service in which a patient’s treating (eg, attending or primary) physician or other qualified health care professional requests the opinion and/or treatment advice of a physician with specific specialty expertise (the consultant) to assist the treating physician/qualified health care professional in the diagnosis and/or management of the patient’s problem without the need for the patient’s face to face contact with the consulting physician. These services are typically provided in complex and/or urgent situations where a timely face to face service with the consultant may not be feasible (eg, geographic distance). 

These codes should not be reported by a consultant who has agreed to accept transfer of care before the telephone/internet assessment, but are appropriate to report if the decision to accept transfer of care cannot be made until after the initial interprofessional telephone/Internet consultation. 

The patient for whom the interprofessional telephone/internet consultation is requested may be either a new patient to the consulting physician or an established patient with a new problem or an exacerbation of an existing problem. However, the consultant should not have seen the patient in a face to face encounter within the last 14 days. 

When the telephone/internet consultation leads to an immediate transfer of care or other face-to-face service (eg, a surgery, hospital visit or a scheduled office evaluation of the patient) within the next 14 days or next available appointment date by the consultative physician, these codes are not reported. 

99446 

Interprofessional telephone/internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician/qualified healthcare professional; 5-10 minutes of medical consultative discussion and review The RUC reviewed the survey results from 48 multi-specialty physicians and determined that the survey respondents overestimated physician work. The specialty societies proposed and the RUC accepted modifications to the survey times to more accurately reflect the CPT descriptor: 3 minutes for pre-service; 8 minutes for intra service; and 5 minutes for post service. The RUC reviewed key reference service, CPT code 99441 Telephone evaluation and management service provided by a physician 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 agreed that 99446 is a more intense procedure. Typically, the patient is unknown to the consulting physician, the service is provided in a complex/urgent situation and the medical decision-making required is more intense than the key reference service. In order to maintain the proper rank order in relation to 99447 (described below), the RUC used magnitude estimation and determined that a work RVU between the survey 25th percentile (0.50) and the work RVU of 99441 (0.25) is appropriate. The RUC also compared 99446 to 99281 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor (work RVU = 0.45) and determined that 99281 is a more intense service and should be valued higher. The RUC recommends a work RVU of 0.35 for CPT code 99446. 

99447 

Interprofessional telephone/internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician/qualified healthcare professional; 11-20 minutes of medical consultative discussion and review The RUC reviewed the survey results from 31 multi-specialty physicians and determined that the survey respondents overestimated physician work. The specialty societies proposed and the RUC accepted modifications to the survey times to more accurately reflect the CPT descriptor: 3 minutes of pre-service; 15 minutes of intra service; and 5 minutes of post service. The RUC reviewed key reference service, 99442 Telephone evaluation and management service provided by a physician 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 agreed that 99447 is a more intense procedure. Typically, the patient in unknown to the consulting physician, the service is provided in a complex/urgent situation and the medical decision-making required is more intense than the key reference service. In order to maintain the proper rank order within the family of services, the specialty society indicated and the RUC agreed that a work of 0.70, lower than the survey 25th percentile is appropriate. The 0.35 increment increase in work RVU is similar to that within the telephone evaluation and management services, 99441-99443. The RUC also reviewed CPT code 99241 Office consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family (work RVU = 0.64 and 15 minutes of intra-service time) and agreed that 99447 should be valued higher since it is typically provided in a complex/urgent situation. The RUC recommends a work RVU of 0.70 for CPT code 99447. 

99448 

Interprofessional telephone/internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician/qualified healthcare professional; 21-30 minutes of medical consultative discussion and review The RUC reviewed the survey results from 31 multi-specialty physicians and determined that the survey respondents overestimated physician work. The specialty societies proposed and the RUC accepted modifications to the survey times to more accurately reflect the CPT descriptor: 5 minutes for pre-service; 25 minutes for intra service; and 5 minutes of post service. The RUC reviewed CPT code 99443 Telephone evaluation and management service provided by a physician 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 agreed that 99448 is a more intense procedure. Typically, the patient in unknown to the consulting physician, the service is provided in a complex/urgent situation and the medical decision-making required is more intense than the key reference service. In order to maintain the proper rank order within this family of services, the RUC used magnitude estimation and determined that a work RVU of 1.05 is appropriate (99447 work RVU of 0.70 + 0.35 = 1.05). The RUC compared 99448 to 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 related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker (work RVU = 1.10) and determined that 99374 is a more intense service and should be valued higher. The RUC recommends a work RVU of 1.05 for CPT code 99448. 

99449 

Interprofessional telephone/internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician/qualified healthcare professional; 31 minutes or more of medical consultative discussion and review The RUC reviewed the survey results from 26 multi-specialty physicians and determined that the survey respondents overestimated physician work. The RUC noted that 99449 will typically be utilized by behavioral/mental health professionals as there is a perceived need with access to care. The specialty societies proposed and the RUC accepted modifications to the survey times to more accurately reflect the CPT descriptor: 9 minutes for pre-service; 31 minutes for intra service; and 10 minutes for post service. The RUC reviewed CPT codes 92014 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits (work RVU=1.42) and 99304 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 25 minutes at the bedside and on the patient's facility floor or unit. (work RVU=1.64) and agreed that both services require less intra-service time and are more intense than 99449. The RUC recommends a work RVU of 1.40 for CPT code 99449. New Technology This service will be placed on the New Technology list and be re-reviewed by the RUC in three years to ensure correct valuation and utilization assumptions.