“I thought these past records would be helpful,” says many a patient as they hand over three triple-sized binders for you to peruse in your leisure time. I’m happy to have these for patient care — but not so thrilled with the non-billable time I’d be devoting. If you’ve been frustrated by the amount of uncompensated time spent caring for your patients, the new Current Procedural Terminology (CPT) billing codes released by the American Medical Association (AMA) may be welcome news. As of January 1, 2021, doctors have more options to bill for the time we actually invest in our patients — from reviewing extensive records to conversations with family members — outside of face-to-face visits. This is the first overhaul in office visit documentation and coding in almost 30 years, since the prior iteration of evaluation and management codes established in 1992. Previously, time could only be used to bill outpatient visits by time when counseling and/or coordination of care comprised more than 50% of the visit, and only time spent face-to-face with a patient counted. Now all that time spent on the day of the visit caring for patients can be billed, with prolonged visit codes billable in 15-minute increments if the visit exceeds the level 5 (99205, 99215) time quotients. Additional codes remain in place for non-face-to-face prolonged services of 30 minutes on a date other than that of the encounter. While these changes should be welcome news to many doctors, especially with practices closing in the COVID-19 pandemic due to financial losses, one has to wonder if we’re heading in the direction of the legal profession where billing practices are considered “a major contributory factor to the discouraging public opinion.”
Since the 1970s, it’s been standard for lawyers to bill by the hour rather than by the service, which has led to negative outcomes that the medical profession may want to heed. When my husband practiced law, he bemoaned the burden of constantly tracking his time so the firm could bill clients for every 6-minute increment. On the client side, I recently had to argue against a $200 bill for emails regarding a spelling error the lawyer made in my business partner’s name. Lawyers have been disciplined for overbilling hours and other unscrupulous billing practices.
Can we avoid a similar hit to the medical profession reputation while still advocating for fair compensation for our time? Understanding the potential risks and benefits may help.
The Potential Benefits of An Expanded Time-Based Payment Model
Physician Burnout: Now with burnout at an all-time high, the excessive time on tasks outside of actually seeing patients and financial stress are among the top contributing factors. While ultimately reducing the burden of administrative tasks is needed to address these causes, the ability to now bill in a way that values the full extent of work (chart reviews, record-keeping, coordination of care, etc.) may make a dent in the demoralizing overwork/underpay syndrome.
Equitable Access: The past decade has witnessed an exodus of doctors to concierge and other non-insurance-based practices in response to dissatisfaction with the current model. This shift, along with the closures of primary care practices in the pandemic, threatens equitable access of patients to care. The new CPT guidelines are an indicator that the AMA recognizes the need to find solutions to keeping doctors, especially our primary care doctors, in practice.
Health System Costs Due to Chronic Disease: Time-intensive fields and those that devote more time to counseling have traditionally suffered in the volume-based reimbursement model (instead of value-based), while studies show that helping patients with behavior change can help prevent disease. In my own practice, I spend a minimum of one hour with new patients, and 30 minutes with follow-up patients; and while I’ve been in practice for almost 25 years, I earn significantly less in the RVUs work model than new primary care grads seeing 4–6 patients an hour where they dash off a prescription or referral. The new billing codes don't make up the difference, and still more needs to be done. Our expensive and failing U.S. health care system, which spends more per person on health than comparable countries with poorer outcomes, needs to understand that compensating doctors who take the time to help patients prevent disease is a core solution (if not the key).
The Potential Risks of An Expanded Time-Based Payment Model
Shifting Cost Burden: If insurance rejects claims, then either the clinic practice will need to eat the cost or the cost burden will shift to the patient. A growing percentage of patients — up to 25% — who don't have the financial resources to take on the growing patient portion of health care costs are foregoing necessary and preventive medical care. In the past year, I’ve also noted a dramatic rise in prescriptions requiring prior authorizations and appeals as insurance companies try to contain costs. It remains to be seen how reimbursement of the new CPT codes will work in reality, and whether they will just add increased work and costs for both offices and patients. If this happens, the previously mentioned benefits could not only fail to manifest, but could reverse course.
Patient Pushback: When considering patients who do have the means to invest in their health, I’ve noticed many resist, expecting that their health insurance should cover it. I’ve witnessed patients "swagged out" in luxury accessories, chatting about their latest spa trip balk at copays, office services like copying records, and services that aren’t covered by their insurance, such as visits to a registered dietician. Without patient re-education, and a larger conversation about why health equals wealth, not the other way around, I can foresee more administrative hassles as clinics deal with patient complaints.
Loss of Trust: Public trust in the medical profession had plummeted pre-pandemic, though there was some recovery during COVID-19. Given the legal profession self-identifying time-based billing as one of the biggest contributors to their negative reputation, the health care industry is at similar risk. If episodes of billing fraud by physicians increase as a result of new opportunities, public trust will degrade even faster. Ultimately, this will lead to poor outcomes for patients, who are less likely to follow the guidance of their clinicians when patient-physician trust is low.
My initial reaction to learning about the new office codes for the extra work I do on behalf of my patients was, “It’s about time!” Having now done a deeper dive into how they actually work, I realize there’s still a long way to go. The guidelines have unnecessary barriers to reimbursement for time. For example, if I spend 15 minutes pre-charting on a patient, reviewing interim visits and tests, I can only include the total time if it is on the actual day of the in-person visit, not the day before. If I spend 25 minutes in conversations with family or specialists on a non-patient care day, I can’t bill that either, as it doesn’t hit the requisite 30-minute mark. And a lack of clarity in the guidelines are a possible minefield for audits: Time cut-offs for when I can bill for prolonged time in a visit differs between the CMS or the AMA. Guidelines on documentation for time billing are vague, raising the risk that audits may lead to rejected claims. Finally, the new codes reward time, not cumulative experience. As we become subject matter experts over time, our clinical acumen allows us to more efficiently complete tasks, such as record reviews, as we can identify issues through a focused lens.
While it will take further CPT iterations to solve some of these issues, we need to work with what we have. At this point, to maximize the benefit:risk ratio, I encourage my colleagues — whether you bill based on time as discussed here or the revised medical decision-making rules — to thoroughly educate yourself, and get assistance from coding experts. Document appropriately so you’re not at risk of audits at the minimum, and fraud at the worst. Monitor what happens to claims once submitted and whether increased costs are being passed onto patients. And most importantly, be prepared to counsel your patients if they question these new charges so we can maintain the trust in the patient-physician relationship.
What are your thoughts on the new CPT codes? Share in the comments.
Dr. Melinda Ring serves as the Director of the Osher Center for Integrative Medicine at Northwestern University, and Clinical Associate Professor in the Departments of Medicine and Medical Social Sciences at the Northwestern University Feinberg School of Medicine. Dr. Ring is board-certified in internal medicine and integrative medicine, and has a special focus in women's health. In her roles at Northwestern, she directs both clinical and faculty fellowships in integrative medicine, teaches the Cooking Up Health culinary medicine course, and researches nutrition and integrative strategies to promote health. She is a 2020–2021 Doximity Op-Med Fellow.