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Patient Messages: Pathway to Payment

Once documented and clipped neatly to the patient’s chart, messages today primarily arrive in an electronic format. Like the days of paper, electronic messages represent a record of the patient’s request. They are inherently accompanied by the record, accessible with just a few keystrokes. The advantages of electronic messaging are many, however, there are some drawbacks. The only individuals in a medical practice without a job description- physicians- are often the victim of the electronic dumping ground. The messages are left in the pool to manage – and physicians are normally the ones to address them.

Given the increasing popularity of patient messages, it’s an opportune time to review some guardrails to consider:

Set the parameters. Be intentional about the use of messages – don’t just issue some announcements and hope that patients will read - and abide - by them. Embed parameters into the messaging system. Review your solution, and determine the best settings for character limits, required data fields, disclaimers, automated responses, and other key protocols. Establish appropriate limits around access – for example, use is limited to established patients only who have been seen in the past 12 months or have an upcoming appointment on the books. Close threads after no activity for 30 days. Sit down with your vendor:  bring your requests to the table for the workflow you seek – and ask for their feedback about best practices using their solution.

Prompt for a visit. Integrate an alternative path to care into the messaging system. Consider prompting the patient about handling prescription refills, test results and referrals so those can be routed appropriately, and not get dumped into a message. (Distribute refill requests to the nurse to handle, for example.) Communicate that appointments are available, with a frictionless link to self-schedule. On the backend, allow the physician to respond to the patient prompting a request for a visit. (Some messages may not be appropriate for a written response, but rather the patient needs to be seen.) Consider enabling on-the-fly telemedicine encounters.

Charge for it. There is a clear path to billing for messages, and it’s time to use it. After some negative press last year, the idea has taken off. Most large health systems are billing for the provider’s time, and patients are responding positively. Most importantly, physicians are grateful for the recognition of the (hard) work. Here’s how to charge: (1) be transparent with patients; for example, “most messages are free; however, if a response requires medical expertise – and more than a few minutes of your doctor’s time, it may be billed to your insurance;” and insert a prompt to which patients must agree when they start a new message; and (2) use online digital evaluation and management services, as represented by CPT® codes 99421, 99422, and 99423, to bill for messaging. (See SIDEBAR for current Medicare reimbursement rates – and tips for reimbursement.)

  • 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: Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 11– 20 minutes
  • 99423: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes.

As noted, the codes require an accounting of time; it’s very difficult to manage it manually. (For example, you must measure the time over a 7-day period.) Meet with your vendor to discuss how to automate.

Mature the message. Determine how to best staff for messages – the answer should not be the physician. Like any type of work, messages should be handled based on working to the top of the license. Consider a focus on “maturing” the message – this refers to how messages are addressed. A medical assistant or LPN may be in the best position to screen and sort messages, curating them while doing so. For example, a message about a troublesome side effect from a medication may prompt the staff to inquire about the nature of the side effect and/or the medication, if the information is left out. Further, some messages may be handled at that initial screen and/or distributed to the appropriate party to address. In sum, develop an internal air-traffic control system for messages. To be effective, the efforts to mature messages require staff training. Take the same approach to message handling as one would for rooming patients in the clinic – create policies, procedures, and protocols for the work. Train staff – and hold them accountable. Larger practices have developed teams of staff who do nothing but handle messages.

Messaging may be challenging to manage, but there is a silver lining. You are leveraging your free employee – your patient. In the past, you had to pay someone to take the message. While it’s frustrating to stare at a voluminous in-box, you didn’t have to pay anyone to fill it. Although certainly not all messages are billable, there is now a pathway to be reimbursed for your time and effort.

2023 Medicare Reimbursement (National Payment Amount)









Source: Physician Fee Schedule. Centers for Medicare & Medicaid Services.


Reimbursement Tips for Online Digital E/M Codes

  • Neither appointment requests nor standard prescription refills qualify; the communication should represent an evaluation and management service.
  • If the communication is less than five minutes, it is not billable. Post-operative care in the midst of the global period is not eligible, unless unrelated to the surgical event.
  • The patient must generate the initial inquiry, although the practice may advertise the availability of the service.
  • Like any billable service, the interaction must be medically necessary.
  • The time-based codes represent communication that may occur over a seven-day period; the time should be combined.
  • The patient must consent to receiving the services, so be sure to address that in your messaging workflow.
  • Coinsurance and deductibles generally apply.

Consult the CPT® Manual and payer guidance for additional information.

About The Author

Elizabeth Woodcock is the founder and principal of Woodcock & Associates. She has focused on medical practice operations and revenue cycle management for more than 25 years. She has led educational sessions for a multitude of national professional associations and specialty societies, and consulted for clients as diverse as a solo orthopaedic surgeon in rural Georgia to the Mayo Clinic. She is author or co-author of 17 best-selling practice management books, to include Mastering Patient Flow and The Physician Billing Process: Avoiding Potholes in the Road to Getting Paid. Elizabeth is a Fellow in the American College of Medical Practice Executives and a Certified Professional Coder. In addition to a Bachelor of Arts from Duke University, she completed a Master of Business Administration in healthcare management from The Wharton School of Business of the University of Pennsylvania. She is currently a doctoral student at the Bloomberg School of Public Health of Johns Hopkins University.

The contents of The Sentinel are intended for educational/informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice, as specific legal requirements may vary from state to state and/or change over time.

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