Prolonged non-face-to-face service: How cardiologists leave money on the table

As Linda Gates-Striby was presenting information about coding and billing practices at the American College of Cardiology’s Cardiovascular Summit in Orlando, Florida, Geoffrey A. Rose, MD, broke in with a message for the audience.

“This next slide is going to pay for your trip,” said Rose, chief of cardiology at Sanger Heart and Vascular Institute in Charlotte, North Carolina.

Based on the murmuring that cascaded throughout the room—and the number of people who rushed to speak with Gates-Striby at the end of the session—Rose was onto something.

The slide that generated the buzz was related to prolonged non-face-to-face time, something providers have long considered a part of the job but that has only been reimbursable through CMS since 2018.

Here’s the gist of the now-billable service: If a provider spends at least 31 minutes “above and beyond” the usual time associated with an E/M (evaluation and management) visit, they can bill for 2.10 work relative value units (wRVUs), equaling $113. Each additional 30 minutes after the first hour beyond the normal visit time—every E/M code has a usual time allotment—is worth 1.0 wRVU, or an average of $55.

The time doesn’t have to be continuous, meaning it’s still billable if a cardiologist spends 20 minutes the night before a visit reviewing a patient’s testing results or medication changes, sees the patient, and then looks over some newly available records or imaging studies for another 15 minutes the following week. These activities can be provided the same day or on a different day than the E/M visit, as long as they’re related to the ongoing management of the patient but outside the scope of the face-to-face visit itself.

“I think clinicians, there’s so many things that they do that are just considered to be inclusive and a part of something else,” said Gates-Striby, director of quality assurance for Ascension Medical Group, Indiana. “Up until the time that Medicare decided to reimburse separately for this, this was just considered to be a part of what you’re being paid for in the office visit itself. It (was) not separately billable that you may have spent 20 minutes reviewing the notes from that referring provider so you could go in better prepared to see that patient.”

Gates-Striby said she was stopped in halls multiple times at the ACC CV Summit to talk about this topic, driving home the point that many conference attendees realized they’d been leaving money on the table for months.

But there are some caveats to the rule:

  • Only provider time counts, so it’s not reimbursable if clinical staff members take time to review notes.
  • Providers can’t bill for time spent reviewing their own notes.
  • The ongoing management associated with prolonged face-to-face time can’t be billed during the same timeframe as transitional care management or chronic care management services.

Gates-Striby said practices will have to come up with their own workflow processes to ensure the additional time spent on complex patients is documented accurately. Most electronic medical records have services attached to an appointment on a specific date, so to document prolonged E/M services performed on a different date, her institution had to go with an old-fashioned paper form and scan it into the EMR to link it to the in-person encounter.

“As much as we really don’t like to have to go back to a paper process, short of having a physician schedule a (separate) appointment for the patient and then documenting their note we couldn’t find a good way to do it,” she said. “So, we developed a form to make it easier for the physician to document the various elements such as labs, or review of actual images, review of reports, surgical hospital encounters, and then that form would be completed by the clinician, given to someone who would enter the charge and then scan it into the medical record.”

Gates-Striby said in the cardiology world, physicians treating heart failure and congenital heart disease are likely to qualify most often for prolonged non-face-to-face time due to their patients’ complexity and extensive medical histories.

According to the Office of Inspector General’s 2018 work plan, “the necessity of prolonged services are considered to be rare and unusual.”

But that’s not to say cardiology practices should overlook this new revenue opportunity.

“I think the OIG would be on the lookout for potential abuse, but when it comes to cardiology and other more cognitive areas of medical practice, I don’t think it’s as ‘rare and unusual’ as they might expect it to be,” Gates-Striby said.