Medicare billing codes for audio-only follow-up check-ins lead to new reimbursement battles.
Maybe this has happened to you recently: Your doctor telephoned to check in with you, chatting for 11 to 20 minutes, perhaps answering a question you contacted her office with, or asking how you’re responding to a medication change.
For that, your doctor got paid about $27 if you are on Medicare—maybe a bit more if you have private insurance.
Behind those calls is a four-digit “virtual check-in” billing code created during the pandemic, for phone conversations lasting just within that range, which has drawn outsize interest from physician groups.
It’s part of a much bigger, increasingly heated debate: Should insurers pay for “audio-only” visits? And, if they do, should they pay the same reimbursement rate as when a patient is sitting in a doctor’s office, as has been allowed during the pandemic?
Cutting off or reducing audio-only payments could lead providers to sharply curtail telehealth services, warn some physician groups and other experts. Other stakeholders, including employers who pay for health coverage, fear payment parity for audio-only telehealth visits could lead to overbilling. Will it lead, for example, to a flood of unneeded follow-up calls?
Robert Berenson, an Institute Fellow at the Urban Institute, who has spent much of his career studying payment methods, said if insurers pay too little, doctors—now accustomed to the reimbursement—might no longer make the follow-up calls they might have made for free pre-pandemic.
But, he added, “if you pay what they want, parity with in-person, you’ll have a run on the treasury. The right policy is somewhere in between.”
Medicare billing codes, while a dull and arcane topic, draw keen interest from doctors, hospitals, therapists and others because they are the basis for health care charges in the United States. Medicare’s verdict serves as a benchmark and guide for private insurers in setting their own payment policies.
Thousands of codes exist, describing every possible type of treatment. Without a code, there can be no payment. The creation of codes and Medicare’s determination of a reimbursement amount, designed to reflect the amount of work involved, prompt ferocious lobbying by the business interests involved. The American Medical Association derives a chunk of revenue from owning the rights to a specific set of physician billing codes. Other codes are developed by dental groups, as well as the Centers for Medicare & Medicaid Services or state Medicaid agencies.
The idea of a “virtual check-in” code began before the pandemic, in 2019, when Medicare included it to cover five- to 10-minute telephone calls for doctors to respond to established patients. It pays about $14.
When the pandemic hit, Congress and the Trump administration opened the door wider to telehealth, temporarily lifting restrictions—mainly those limiting such services to rural areas.
Meanwhile, CMS this year added a billing code for longer “virtual check-ins”—11- to 20-minute calls—with payment set at about $27 a pop, with the patient contributing 20 percent in copayment. Such calls are meant to determine whether a patient needs to come in or otherwise have a longer evaluation visit, or if their health concern can simply be handled over the phone.
And physicians argue that allowing payments for audio-only care is a positive step for them and for their patients.
“I take care of patients who drive from two or three hours away and live in places without broadband access,” said Jack Resneck Jr., M.D., a dermatologist and president-elect of the American Medical Association. “For these patients, it’s important to have a backup when the video option doesn’t’ work.”
Still, the focus on telephone-only care has raised concerns.
“Here’s an invitation to convert every five-minute call into an 11- to 20-minute call,” said Berenson.
The Medicare code allows “other qualified health professionals,” such as physician assistants or nurse practitioners, to bill for such calls. Private insurers would set their own rules about whether non-physicians can bill for follow-up calls. It’s not clear how much of a revenue stream dedicating such staff members to make these short, telephone check-ins would create for a medical practice.
To avoid overuse, CMS did set rules: The code can’t be used if the call takes place within seven days of an evaluation visit, either in person or through telemedicine. Nor can a doctor bill for the call if he or she determines the patient needs to come in right away.
When the health emergency ends, however, so do most audio-only payments. The emergency is expected to last at least through the end of the year. Congress or, possibly, CMS could change the rules on audio-only payments, and much more lobbying is expected.
While the virtual check-in codes have been made permanent, physician groups are lobbying for Medicare to retain a host of other telephone-only-visit codes created during the pandemic, including several that allow physicians to bill for telephone-only visits in which the doctor potentially diagnoses a patient’s condition and sets up a treatment plan.
For those, considered “evaluation and management” audio visits, Medicare during the public health emergency has paid about $55 for a five- to 10-minute call and $89 for one that runs 11 to 20 minutes—the same as for an in-office visit.
“Whether we see patients in house, by video or by phone, we need the same coding” and the same payments, because a similar amount of work is involved, said Ada Stewart, M.D., the board chair for the American Academy of Family Physicians.
Many patients like the concept of telehealth, according to Suzanne Delbanco, executive director of Catalyst for Payment Reform, a group representing employers who want payment methods for health care to be overhauled. And, for some patients, it’s the easiest way to see a doctor, especially for those who live far from urban areas or are unable to take time off work or away from home.
But, she said, employers “don’t want to get locked into paying more for it than they have in past, or as much as other [in-person] visits when it’s not truly the same value to the patient.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.