“Virtual” peer reviews are a covered benefit for most payers.
In keeping with our theme of “communication-based services,” let’s take a closer look at the inter-professional consults and referrals that do not include a face-to-face encounter with a patient. Some are existing CPT® codes, and two new codes, in this section, were also added for further clarification.
New in 2019 are the following:
A patient may be new to the consultant, or an established patient with a new problem or an exacerbation of an existing problem may present to the consulting provider. However, there are “global days” that come with these services.
The consultant should not have seen the patient in a face-to-face encounter within the last 14 days, or if the health record consultation leads to a transfer of care or other face-to-face services, such as a surgery, evaluation, and management (E&M) visit, or procedure, within the next 14 days, or next available appointment. If this is the case, these codes should not be reported.
If more than one call or communication with the consultant is needed to complete the consultation request (example: discussion of test results), the entirety of the complete service and the cumulative discussion and information review time should be reported with a single code. Do not report these codes more than once in a seven-day period, per CPT.
What are these services for?
These services are in effect a “peer-to-peer” review. These take place when a patient’s treating (attending or primary) physician requests the opinion and/or treatment advice of another physician with specific specialty expertise (the consultant), above and beyond that of the treating physician, to assist the treating physician in the diagnosis and/or management of the patient’s problem, without patient face-to-face contact with the consultant.
These services are not subject to the telehealth rules or restrictions Medicare has put on other telemedicine services, which include geographical location or originating site requirements.
This is new territory when it comes to insurance coverage, and it will be up to the business office to keep a close eye on the rules and global days. Practices should have a plan and protocols in place to make sure that if these services are billed, there is a compliance plan in mind to avoid patient complaints and payor refund requests.
Also of note, when the sole purpose of the telephone/Internet/electronic health record communication is to arrange a transfer of care or other face-to-face services, then these codes are not reported.
You can read the full definition of these codes in the 2019 American Medical Association (AMA) CPT® Professional Edition Code Book.
Programming Note:
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