There has been a proliferation in the use of HIPAA (Health Insurance Portability and Accountability Act)-compliant online patient portals, which allow practitioners and practices to communicate to patients and vice versa in a secure manner. There are benefits (such as practice and communication efficiencies) along with challenges with such portals. Portal messages can range from seemingly mundane requests such as scheduling visits or refilling prescription, to communicating results and providing medical updates, to seeking medical care. Providers may feel empowered with portals by having the ability to communicate without the need to reach out by phone, while others at times have described feeling overwhelmed with the number of messages received and expressing concerns about somewhat blurred boundaries regarding appropriate patient portal communications. Recent headlines state that some institutions are now charging for patient portal messages. This certainly has led to confusion among both practitioners and patients, with both questioning what those headlines mean and what can or cannot be charged to a patient. Clarification is needed to protect the patient, practice, and practitioner. So what is really going on and what can be coded and billed?

It is important to not take the headlines about charging for portal messages at face value, as one needs to read further into the details to see what is and what is not able to be charged. On a high level, most portal messages are not able to be billed. There are specific rules and limitations on what can be charged, and basically it is only when a practitioner provides true online Evaluation and Management (E/M) service through the online portal. Even E/M services that are provided comes with a number of restrictions and some limitations.

The 3 currently available CPT (Current Procedural Terminology) codes that describe and can be used to report online digital E/M services are:

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

99422 …11-20 minutes

99423 …21 or more minutes

As per the descriptor, these online digital E/M services can be reported only when a provider performs a true E/M service using the online portal. Limitations include providing these services only to an established patient and when done in place of a face-to-face E/M encounter. The visit must be medically necessary, patient-initiated (such as in response to a new or worsening problem), and it must be for a condition or problems that can actually be managed by message/portal without needing a face-to-face visit. The service must take at least 5 minutes of physician time (note that office staff and clinical staff time does not count). What does not count: communication of test results, refilling medications, changing medications due to cost or formulary, scheduling appointments, and messages that can be handled by clinical staff and do not require clinician expertise, or even patient management that takes less than 5 minutes of a practitioner’s time. Time is cumulative and additive for up to 7 days, meaning if multiple online portal messages are used for the E/M visit then 1 code with the summed time only should be reported. It cannot be reported on a day when the provider reports other E/M services on the same patient. Also, if the online communication results in an in-person visit within 7 days then the time or complexity of the portal message work is incorporated to the code selection (time or medical decision-making) of the in-person visit and the online service is not reported. One should not report these services if within a global period a surgical procedure, unless the service is medically necessary and unrelated.

Chart documentation is mandatory to support medical necessity and code selection. Documentation should describe the medical necessity for the visit, a medically appropriate history, a review of any results of testing, and the management plan for the condition including the tests ordered and treatments provided. Documentation should also include the total amount of time spent by the practitioner(s) for the service. As with any billable service, one should strongly consider obtaining and documenting patient consent for such as service. There are some institutions that post their billing policies online, while others put them in their offices. Best practice is documentation that the patient is aware that the service is billable to their insurance company so they are not surprised when they see a bill or a charge, as patients may also be responsible for a deductible and/or co-pay based upon their insurance. Note that for Medicare these services are typically covered albeit patients may be responsible for 20% of the cost if they do not have a secondary insurance. One should also consider offering (and documenting) that the patient was given an option of a face-to-face visit and they chose to proceed with the portal visit.

As with any billable service, there is also a risk of being accused of fraudulent billing and/or breaking a contract with a private insurer. One could certainly put themselves at risk of audits and take-backs for incorrect use of these codes. Therefore, understanding what is and is not reportable and having documentation to back up the submitted codes is of utmost importance. Additionally, there is a medicolegal risk to performing online E/M services. Online E/M services do not afford a provider of either verbal or visual communication that often is so vital to a productive visit. One should strongly consider recommending an in-person visit with nearly any patient interaction, especially if a patient should be seen and/or examined for their concern.

In summary, the proliferation of portal messages has positive and negative implications and its own set of benefits and challenges. There are significant time and communication benefits and practice efficiencies gained from such communication, but can also come at a cost. In urology, there are likely certain patients that may qualify for online E/M services. If charging patients for online E/M services, one has to remember that it needs to serve as a substitution for an in-person E/M visit. Documentation of such can protect both the patient and the practice. One needs to have a true understanding of what is billable and not billable. A practice must consider how they acquire a patient’s consent for this service along with offering an in-person evaluation and proving the patient is choosing to receive their care by portal messaging.