Will Billable Online Consultation Replace Costly Telephone Time?

Boston–At a two-physician epilepsy care office in Arizona, nurses spend almost three hours a day dispensing free advice–at an annual cost of $13,286. When the physicians pitch in, that price swells to $54,345. Why do they do it?

"A large part of epilepsy treatment requires telephone contact, and all of this time is unreimbursed," explained Deborah Shulman, RN, the nurse coordinator of the Comprehensive Epilepsy Center at the Mayo Clinic Scottsdale, in Arizona. Looking to quantify just how much the old adage, "Time is money," applies to medical care, Ms. Shulman logged and categorized the more than 80 patient telephone calls received during a random two-week period. The calls consumed about 14 hours per week, or 2.8 hours per day.

She urged neurologists to ask themselves, "Do you need more than one nurse in an epilepsy program if this much time is spent on the telephone? Also, can a non-nurse provider respond to [requests for] medication refills or general information?"

Neil Busis, MD, chief of neurology at the University of Pittsburgh Medical Center Shadyside, and a member of the Medical Economics and Management Subcommittee of the American Academy of Neurology (AAN), suggested a more high-tech answer: e-mail. It would "allow physicians and staff to more efficiently triage their time," he said.

For example, in Ms. Shulman’s report, medication refills took up 4.4 of the 14 hours of telephone time each week. The rest consisted of patient counseling and education. E-mail communication would allow physicians to answer a block of refill queries while a nurse or other staffer handles counseling. Also, although telephone call exchanges should all be documented for medicolegal reasons, this paperwork often is neglected by busy clinicians, especially in on-call situations. E-mail would solve that problem.

"It is self-documenting, can be done 24/7 at your own convenience, avoids disruptions to patient care and reduces errors inherent in secondhand message transmission through office staff," said Orly Avitzur, MD, MBA, a neurology lecturer at Yale University School of Medicine in New Haven, Conn. Dr. Avitzur rattled off a long list of advantages to e-mail, including the fact that this form of communication "facilitates the use of Web-based questionnaires that ultimately become a documented part of the patient record, and allows for efficient relay of patient educational material and embedded links to physician-approved Web sites," not to mention easing the administrative burden that health insurance imposes.

But how can the system efficiently ease insurance woes if the insurance it is designed to work with doesn’t cover electronic consultations?

"If relative value units are assigned to online communications, and they reimburse physicians for their time, this mechanism of communication will become increasingly more popular and even replace some telephone calls, with time," Dr. Avitzur predicted.

That time may be soon, as the American Medical Association (AMA) announced in January the addition of Current Procedural Terminology (CPT) code 0074T, for online medical evaluation. According to the AMA, this code will go into effect on July 1, 2004, and will cover all communications with patients related to online inquiries (sidebar). Representatives from the AMA said it released the code several months in advance, to give providers time to add it to their databases.

Statistics reflecting physician use of the Internet for patient care differ by source, but a recent Jupiter survey found that only about 9% of U.S. doctors e-mail patients more than five times per week, and the majority of those contacts were for appointment scheduling or billing questions. Another survey, by emarketer.com, found that the figure was closer to 13%.

As of now, most physician offices are still in a comparative Dark Age. At Ms. Shulman’s office, the most advanced phone-based technology is a "call center to prioritize the calls and be more efficient," she said.

For the time being, if most patients and physicians prefer to dial than type, then perhaps e-mail coding is less important than fixing the problem of reimbursement for telephone consultation. "Although Medicare has service codes for telephone calls [codes 99371-99373], it will not pay for them as it considers payment for telephone calls included in billable services such as office visits or surgery," Dr. Avitzur said. "Most fee-for-service third-party payers will not pay these codes, and care provided by nurses is not included in these code descriptions."

Among organizations pushing for telephone consultation reimbursement is the American Academy of Pediatrics. In addition, the AAN is helping the Centers for Medicare & Medicaid Services (CMS) and the AMA revamp the evaluation and management codes, Dr. Busis reported. "A change in CMS policy to allow reimbursement for patient encounters that are not face-to-face is an excellent idea and would greatly foster the adoption of electronic solutions to patient communication that would enhance our productivity and decrease the hassle factor in medical practice. The face-to-face rule hampers all kinds of telemedicine."

Help incorporating electronic solutions into the physician’s office is available from the AAN.

–Andrew Wilner, MD, FACP, FAAN and Jennifer Kulpa