Thinking Out Loud: There’s a Code for Medical Billing for Email

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I remember answering patients’ questions in the office (or on the phone later when the fog of what I had told them had dissipated) and there were other “concerns.” Today, more and more doctor-patient discourse is digital and comes at a cost, both financial and medical.

Back in the day, the office staff answering the phone was my means of protecting my time. They would take messages and deflect calls. Today, with the advent of portals, those protections have been lost, only to be replaced by the castle-guarding moat of email. I am not sure exactly how I feel about texting or email, although I must admit I am doing it more and more as a patient. But perhaps because I was “in the trade,” most of my digital communication has been relatively direct and free of charge. But charging for physician email response are becoming a thing.

The New York Times covered the problem earlier this year. Cleveland Clinic, along with the VA, among other health systems, is charging a “co-payment” for the service imposed on patients as we are all herded into patient portals for communication. Of course, there is a code for this digital service. CMS approved Medicare billing codes in 2019, and private insurers have followed suit to varying degrees.

There are some reasons why charging for those last-minute questions makes sense. First, in a world increasingly dominated by providers paid on the clock for their work (as relative value units), responding to email takes time. There is no doubt that email to physicians has dramatically increased during the pandemic, rising by 150% or more. Numbers are hard to come by, but physicians, on average, spend about an hour a day on their email, and at least a percentage of that is done outside the office – digital communications often blurs the work-life balance. Another study found that physicians spend a little over 2 minutes responding to an email question. One might note at this point that CMS requires a minimum of 5 minutes responding to initiate a bill for this digital service – but who is punching a time clock?

Responding to patients’ questions, whether in person or virtually, is a form of medical consultation. At a minimum, the physician must be cognizant of the patient’s history, hopefully understanding their current health concerns and be able to access pertinent laboratory or imaging information in order to provide professional advice. Of course, when a physician gives advice, there attaches to use a legal phrase, liability. To adequately defend against such concerns, text messages must be added to the clinical record, an additional time cost.

Charging for email correspondence has resulted in a win-win for some bean counters. A study at UCSF before and after adopting a charge for email demonstrated that email messaging and back-and-forth texting decreased after fees were introduced, but virtual visits increased – those small email fees drove more patients into more remunerative e-visits. What is unclear is whether these charges, which reduce the demand for access, resulted in poorer care. One would hope that synchronous face-to-face communication, even over video, would be better than the asynchronous back-and-forth of texting. Looming large over that discussion are the disparities of care already baked into the system by those patients without the proper digital tools, insurance, or inadequate coverage for this form of care.

I freely admit I am no longer practicing, so my sense of how well the physician-patient relationship is maintained in these circumstances is unclear. To the extent that I prefer a face-to-face conversation over a telephone call, I am a curmudgeon. I use email extensively, but I am put off by texting. There is, of course, an entire generation raised on texting and email that may be far more comfortable, but I defer. On the other hand, as a physician, I have experienced the power of “laying on of hands” and soft conversation, so while I defer judging, I can’t help but feel this digital back-and-forth will ultimately fail in the moments you need a physician the most.