During the COVID-19 Pandemic, Have You Considered Interprofessional Technology-Based Consultations?

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure accuracy. However, HMP and the author do not represent, guarantee, or warranty that coding, coverage, and payment information is error-free and/or that payment will be received.

Ever since the COVID-19 public health emergency (PHE) was declared, this author has fielded hundreds of calls pertaining to the need for 1) providing wound/ulcer management in untraditional situations and 2) coding and payment guidelines for these situations. While many of the calls centered on telehealth, many others pertained to the need for interprofessional consultation.

Because the theme of this month’s Today’s Wound Clinic is multidisciplinary wound/ulcer management, this author is sharing some ways that wound/ulcer management physicians can consult with other physicians/qualified health care professionals (QHPs) who do not have the same expertise, and can consult with other specialists to guide them in managing underlying diagnoses. Following are the four most common calls this author received about the need for interprofessional wound/ulcer management consultation.

Primary care physician working in a private office: “I normally refer my patients with diabetic foot ulcers, venous ulcers, and pressure ulcers to the hospital owned outpatient wound/ulcer management provider-based department (PBD). Unfortunately, the PBD was closed shortly after the PHE was announced. For many COVID-19-related reasons, my patients do not want to be referred to the next nearest wound/ulcer management PBD, which is over 100 miles away. I could probably manage most of the early-stage ulcers if I had some guidance from a wound/ulcer management specialist …”  

Internal medicine physician who works full-time in a PBD: “Although I am the only physician who works in the PBD, I usually talk with many other specialists who work in the same hospital. If I have a difficult wound/ulcer management situation, I usually receive a casual “hallway consultation” from one or more of the specialists. The COVID-19 PHE has tremendously limited my access to these specialists. I know I can do telehealth visits with my patients, but how can I consult with the specialists …”

Nurse practitioner who works full-time in a multidisciplinary PBD: “Seven multidisciplinary specialists normally work with me in the PBD for one or more days each week. Therefore, prior to the COVID-19 PHE, I always had specialists to advise me on difficult cases and/or to examine the patient and decide next steps. Ever since the COVID-19 PHE began, the specialists were deployed to other areas of the hospital. I need a way that I can ask them for advice and have them get paid …”

Podiatrist who provides diabetic foot ulcer management visits in patients’ homes: “During my home visits, I often encounter a situation that I believe needs the expertise of another specialist. In those cases, I arrange for the patients to see appropriate specialists. During the COVID-19 PHE, many of those specialists’ offices are closed or the patients are not willing to risk exposure by leaving their homes. In some cases, I could manage the patients with the guidance of the specialists, but I doubt the specialists will assist me without being paid …”

Are Interprofessional Technology-Based Consultations the Solution?

All the callers knew about telehealth and many of them had already incorporated telehealth visits, for patients who did not require procedures, into their practices. But the situations described above were about the lack of multidisciplinary wound/ulcer management colleagues to consult with.

All the situations could be easily remedied by taking advantage of the interprofessional technology-based consultation codes that the American Medical Association (AMA) released in 2019. When this author asked the callers if they had considered using these new codes, not one person had ever heard about the codes. In fact, when this author said the word “consultation” to the callers, nearly everyone responded by saying, “but Medicare does not pay for consultations.” When this author explained that Medicare does pay both the treating/requesting physician/QHP and the consulting physician for interprofessional technology-based consultations, the callers were interested in learning more.

See Table 1 for a complete description of the code that the treating/requesting physician/QHP should use and several codes from which the consulting physician can choose. If you decide to take advantage of the interprofessional technology-based consultations, be sure to read the introduction to these codes in this year’s Current Procedural Terminology (CPT^®) Manual.¹ The following are highlights of the easy-to-implement coding guidelines for these interprofessional technology-based consultation codes.

Treating/Requesting Physician/QHP Code

•    The AMA released 1 code (99452) for the physician/QHP who is treating the patient and requesting an opinion or treatment advice from another physician with specific specialty expertise.

•    99452 is used to report the time spent in preparing for the communication with the consulting physician so she/he uses the consultant’s time wisely. The code should only be reported if the physician/QHP spent 16–30 minutes preparing for the referral and/or communicating with the consultant.

•    99452 should only be reported once in a 14-day period.

•    If the treating/requesting physician/QHP wants information to simply improve her/his knowledge, 99452 cannot be reported.

Consulting Physician Codes

•    The AMA released 5 codes (99451, 99446, 99447, 99448, and 99449) for the consulting physician to use when she/he consults to a physician/QHP regarding a diagnosis or management of a patient’s problem. These codes include review of pertinent medical records, laboratory studies, imaging studies, medication profile, pathology specimens, etc.

•    The consulting physician does not have any interaction with the patient and should not have seen the patient in a face-to-face encounter within the last 14 days.

•    If the consultation leads to a transfer of care or other face-to-face service for the patient within the next 14 days or next available appointment date of the consultant, these codes should not be reported.

•    The differences between 99451 and 99446–99449 are:
o 99451 does not include verbal interaction between the requesting physician/QHP and the consultant; it only requires a written report. The service time is based on total review and interprofessional communications time.
o The codes 99446–99449 require both verbal interaction with the requesting physician/QHP and a written report. Greater than 50% of the service time must be spent performing the medical consultative verbal or Internet discussion. If greater than 50% of the service time is spent on data review and/or analysis, 99446–99449 should not be reported. That is unlike the service time for 99451, which is based on total review and interprofessional communications time.

•    These codes should not be reported more than once within a 7-day period.

General Coding Rules for Both the Treating/Requesting Physician/QHP and the Consulting Physician

•    The interprofessional technology-based consultation codes may be billed only by practitioners who can bill Medicare independently for evaluation and management services.

•    The interprofessional technology-based consultation service must be medically necessary for the patient (new or established)

•    The treating/requesting physicians/QHP must obtain consent from the patient to request the consultation because the patient will be responsible for the copayment. The Centers for Medicare & Medicaid Services (CMS) only require the consent to be obtained once a year. The consent of the patient must be noted in the medical record.

•    Because the interprofessional technology-based consultation codes are time based, all the physicians/QHPs involved must track and document the time spent on the service.

•    If more than one contact is required to complete the consultation, all the time should be accumulated and reported with a single code.

•    Do not report these codes if the sole purpose of the communication is to arrange a transfer of care or other face-to-face services.

•    Effective January 1, 2019, the CMS recognized the interprofessional technology-based consultation codes as active, separately reimbursable codes on the Medicare Physician Fee Schedule (MPFS). See Table 2.

Summary

By now you should clearly understand why this author offered the interprofessional technology-based consultations as a solution for the scenarios described above. The primary care physicians can easily request a technology-based consultation from a wound/ulcer management specialist. The internal medicine physician can request a similar consultation from any of the specialists he typically relies upon.

The nurse practitioner should not feel like she/he is imposing on the specialist from whom she/he requests an interprofessional technology-based consultation. And last, but not least, the podiatrist should feel comfortable requesting an interprofessional technology-based consultation until the patient can get into the specialist’s office.

These new codes support a team-based approach to wound/ulcer management. In addition, instead of physicians doing free “hallway consultations,” both the requesting and the consulting physicians are paid by Medicare for their medically necessary work. Although the use of these codes is new to wound/ulcer management physicians/QHPs, many other medical specialties have been taking advantage of these consultation opportunities ever since the codes and MPFS allowable rates were released in 2019.

During the COVID-19 PHE, the interprofessional technology-based consultation codes have proven to be more useful than the AMA or the CMS ever expected. In fact, all the callers described above were quite thankful to learn about the codes and the Medicare payment, and they understood why this author offered interprofessional technology-based consultations as a solution to their current COVID-19 PHE situations. Many of them have since reported that they have begun requesting and receiving the interprofessional technology-based consultations, and both the treating/requesting physicians/QHPs and the consulting physicians have found the process to be quite successful. They also reported that they plan to continue doing some consultations this way even after the COVID-19 PHE ends.

If you are a wound/ulcer management physician/QHP who could use consultation from other specialists, do not hesitate to request an interprofessional technology-based consultation from them. In addition, if you are willing to offer interprofessional technology-based consultations to physicians/QHPs who may be struggling to manage their patients’ wounds/ulcers, you should make a concerted effort to let colleagues in your area know that you are available to share your expertise with them.

Kathleen D. Schaum is a founding member of the Today’s Wound Clinic editorial advisory board and oversees a consulting business. She can be reached for consultation and questions by emailing kathleendschaum@bellsouth.net.

 

1. American Medical Association. Current Procedural Terminology (CPT®) Manual. 2020