Abstract
This study assesses US trends in e-visit billing using national all-payer claims.
At the onset of the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS) and other payers broadly expanded telemedicine reimbursement, including for e-visits. E-visits are asynchronous patient messages requiring medical decision-making and at least 5 minutes of clinician time over 7 days, with patient consent for billing.1 Many health systems have begun billing for e-visits to increase revenue and compensate clinicians for responding to the increasing number of patient-initiated messages.2,3,4 This practice has generated controversy given that patients are unsure which messages will trigger a bill and concerns that billing may discourage messaging.5 It is unclear how many e-visits are being billed, how many organizations are billing e-visits, and what clinical conditions are being billed. To inform health system decision-making on e-visits as well as the policy debate on uptake and spending, this study assessed trends in e-visit billing using national all-payer claims data.
Methods
We used the Trilliant Health6 all-payer claims database, which includes Medicaid, Medicare Advantage, private payer, and traditional Medicare claims representing patients from all 50 states and the District of Columbia. The data are ingested from CMS, commercial payers, and clearinghouses and are aggregated and cleaned, date back to 2017, and include a mean of 272 509 331 unique individuals with at least 1 claim in a given year. We identified claims for e-visit Current Procedural Terminology (CPT) codes (99421-99423) from January 2020 to September 2022. We measured e-visit claims, in total, by CPT code, and as a proportion of all evaluation and management (E&M) visits monthly, as well as the number and proportion of unique organizations (determined by type 2 National Provider Identifier [NPI] and address where service was rendered) billing at least 50 e-visits in each quarter to identify organizations regularly billing for e-visits and exclude those with very few e-visits or accidental claims. In addition, we identified the 10 most common associated diagnosis codes for each CPT code. Analyses were conducted using Databricks version 13.3 LTS. This study was deemed exempt from review by the University of California, San Francisco, institutional review board.
Results
There were a mean of 103 127 e-visit claims per month in 2020 (0.2% of all E&M visits), 77 164 in 2021 (0.1%), and 100 541 in 2022 (0.1%; Figure). Claims peaked in April 2020 (202 272 claims), fell to a post-COVID low in June 2021 (64 341), and rebounded to 107 442 in September 2022. Over the study period, the most common CPT codes were 99421 (5-10 minutes; 44.8%) and 99422 (11-20 minutes; 40.4%), followed by 99423 (≥21 minutes; 14.8%). In the third quarter of 2022, 471 unique organizations (0.5% of all organizations) billed at least 50 e-visits, an increase of 39.8% compared with the same period in 2021.
Figure. E-Visit Volume by Current Procedural Terminology Code and Number of Care Delivery Organizations Billing.
Care delivery organizations billing a minimum of 50 e-visits in each quarter. CPT indicates Current Procedural Terminology.
The most common diagnoses associated with CPT code 99421 were acute sinusitis (7.1%), urinary tract infection (7.0%), and acute respiratory infection (4.5%). For code 99422, they were acute respiratory infection (4.2%), acute sinusitis (4.1%), and hypertension (3.8%; Table). E-visits for CPT code 99423 were most commonly associated with diagnoses for hypertension (18.0%).
Table. Top 10 Diagnosis Codes Associated With Billed E-Visits, by Current Procedural Terminology Code (N = 3 068 367).
| Current Procedural Terminology Code | |||||
|---|---|---|---|---|---|
| 99421 (5-10 min) | 99422 (11-20 min) | 99423 (≥21 min) | |||
| Diagnosis | No. (%) | Diagnosis | No. (%) | Diagnosis | No. (%) |
| Acute sinusitis | 97 530 (7.1) | Acute respiratory infection | 52 674 (4.2) | Essential (primary) hypertension | 81 506 (18.0) |
| Urinary tract infection | 96 931 (7.0) | Acute sinusitis | 50 940 (4.1) | Encounter for general adult medical examination without abnormal findings | 58 646 (13.0) |
| Acute respiratory infection | 61 225 (4.5) | Essential (primary) hypertension | 47 459 (3.8) | Contact with and (suspected) exposure to other viral communicable diseases | 15 562 (3.4) |
| Essential (primary) hypertension | 40 487 (2.9) | COVID-19 | 43 420 (3.5) | Contact with and (suspected) exposure to COVID-19 | 11 494 (2.5) |
| COVID-19 | 36 350 (2.6) | Acute pharyngitis | 28 030 (2.3) | Encounter for observation for suspected exposure to other biological agents ruled out | 11 482 (2.5) |
| Contact with and (suspected) exposure to other viral communicable diseases | 33 770 (2.5) | Urinary tract infection | 26 151 (2.1) | Alcohol dependence, uncomplicated | 10 209 (2.3) |
| Contact with and (suspected) exposure to COVID-19 | 32 907 (2.4) | Acute cystitis without hematuria | 22 281 (1.8) | COVID-19 | 7236 (1.6) |
| Candidiasis of vulva and vagina | 29 982 (2.2) | Cough | 21 213 (1.7) | Type 2 diabetes with hyperglycemia | 7064 (1.6) |
| Acute pharyngitis | 25 667 (1.9) | Rash and other nonspecific skin eruption | 20 206 (1.6) | Type 2 diabetes without complications | 5456 (1.2) |
| Cough | 23 887 (1.7) | Viral infection, unspecified | 17 434 (1.4) | Chronic pain syndrome | 4007 (0.9) |
Discussion
Billing for e-visits peaked at the onset of the pandemic, fell, and then rebounded slowly, whereas the number of organizations billing e-visits has increased since mid-2021. Together these findings suggest health system interest in e-visit billing has evolved from a short-term pandemic necessity to a potential long-term source of revenue. E-visit claims for shorter periods were largely for acute diagnoses such as sinusitis or urinary tract infection, whereas longer e-visits were more often associated with chronic conditions including hypertension. This variation may suggest that shorter, lower-cost messages may substitute for synchronous acute care, whereas longer, more complex messaging is more often an additional care touch point.
This study has limitations, including inability to assess what proportion of messages were billed to assess intensity of e-visit billing relative to patient message volume. Future research is needed to understand whether e-visits are cost-effective, improve patient health, or substitute for synchronous visits, and what drives organizations to start and stop billing for them.
Section Editors: Jody W. Zylke, MD, Deputy Editor; Karen Lasser, MD, and Kristin Walter, MD, Senior Editors.
Data Sharing Statement
References
- 1.Gross GN. Coding telemedicine visits for proper reimbursement. Curr Allergy Asthma Rep. 2020;20(11):73. doi: 10.1007/s11882-020-00970-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Holmgren AJ, Byron ME, Grouse CK, Adler-Milstein J. Association between billing patient portal messages as e-visits and patient messaging volume. JAMA. 2023;329(4):339-342. doi: 10.1001/jama.2022.24710 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Holmgren AJ, Downing NL, Tang M, Sharp C, Longhurst C, Huckman RS. Assessing the impact of the COVID-19 pandemic on clinician ambulatory electronic health record use. J Am Med Inform Assoc. 2022;29(3):453-460. doi: 10.1093/jamia/ocab268 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Nath B, Williams B, Jeffery MM, et al. Trends in electronic health record inbox messaging during the COVID-19 pandemic in an ambulatory practice network in New England. JAMA Netw Open. 2021;4(10):e2131490. doi: 10.1001/jamanetworkopen.2021.31490 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Judson TJ, Subash M, Harrison JD, et al. Patient perceptions of e-visits: qualitative study of older adults to inform health system implementation. JMIR Aging. 2023;6:e45641. doi: 10.2196/45641 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Oakes AH, Boyce K, Patton C, Jain S. Rates of routine cancer screening and diagnosis before vs after the COVID-19 pandemic. JAMA Oncol. 2023;9(1):145-146. doi: 10.1001/jamaoncol.2022.5481 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Sharing Statement