"Face-to-Face" in outpatient E/M does not exclude video chat

Video chat medical consultations are coded as Evaluation and Management (E/M) "Office or Other Outpatient Services" (99201 to 99215) ---just like any other outpatient consultation, no special code needed.

So?

Video chat medical consultations can be provided to patients as a new service without changes to existing medical insurance billing practices. Video chat also has the benefit that it is recorded, replayed, and shared with perfect fidelity. Video does not replace physical consultation, but it does efficiently distribute and triage limited medical consultation resources worldwide while automatically documenting medical events electronically.

Why?

The E/M criteria for "office and other outpatient visits and office consultations" includes "face-to-face" patient interaction defined by the AMA as "time that the physician spends face-to-face with the patient and/or family. This includes the time in which the physician performs such tasks as obtaining history, performing an examination, and counseling patients." ("CPT 2009" pg. 5) This constraint contrasts with the "unit / floor time" criteria used for E/M hospital coding, which by noting a physical location, is actually more constraining physically than outpatient CPT coding which does not specify any physical proximity ---only "face to face."

Clearly, video chat is "face-to-face." If it were not, then what is the purpose of the "video" in "video chat"?

However, outpatient E/M codes 99201 to 99215 do explicitly exclude "communicating further with other professionals and the patient through written reports and telephone contact." That is, voice and written communication without the "face-to-face" real-time visual contact ---the video--- does not qualify.

Objections

Because video chat is "electronic," some believe video chat should be coded as 99444. No! According the AMA definition for 99444, video chat cannot be coded as a 99444 because:

FAIL 1) "non-face-to-face" Video is face to face.

FAIL 2) "physician's personal timely response to the patient's inquiry" Video is face-to-face consultation, not a delayed response to recorded inquiry, as implied by "timely response"

FAIL 3) "this service is reported only once for the same episode of care during a seven-day period" 99444 is an asynchronous exchange of messages, as implied by "during a seven-day period. Video is synchronous, and each "event" is a uniquely submitted "episode of care."

99444 is clearly for web forum and email threads, not video (FAIL 1: face-to-face), not chat (FAIL 3: sync), and not voice (FAIL 2: immediate response, FAIL 3: sync).

Also, some believe that a physical examination is necessary to code outpatient E/M events. This is also a myth. The AMA CPT code book has no qualification explicitly requiring tactile examination to qualify "extent of examination." The only coding qualifications specified are:

- clinical judgment
- nature of presenting problem
- quantity of organ systems / body areas examined

Thus, the limiting qualification is the clinical necessity for physical contact, which is what it should be. If the patient needs to visit the office, the patient needs to visit the office. If not, then not. Not sufficiently examining as clinically indicated is already known as "not doing your job," and inflating a clinical note is already known as "lying." There's no need for a special qualification just because the doctor uses new, better tools.

But yes, in practice, video will probably be coded lower on average than physical examinations ---all else equal--- because the provider will be unable to physically interact with the patient. However, for many routine medical consults, physical interaction is clinically unnecessary unless specifically indicated otherwise.