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To Charge, or Not to Charge, That is the Question...

Good communication is critical to the physician-patient relationship. Technology has made communication easier, faster, and more efficient in healthcare, especially through secure, HIPAA compliant encrypted e-mail and online communication. Patients have readily embraced and adapted to communicating with their healthcare providers online, a practice accelerated by the widespread use of telehealth during the pandemic.

According to a 2021 study in the Journal of the American Informatics Association, “Patient emails to doctors jumped to 157% of their pre-pandemic average by the end of 2020. There was a sudden explosion of message volume.” For example, Cleveland Clinic noted that messages sent through its patient portal doubled since 2019. Dr. Sandra Hong, Director of Cleveland Clinic Food and Allergy Center, stated “We actually receive an average of about 110,000 MyChart messages that require medical advice a week.”¹ Both large and small healthcare entities have experienced exponential increases in online communications.

Online communication and technology provide benefits to both patients and healthcare professionals. Patients may receive on-demand care and treatment without the burden or inconvenience of scheduling an appointment, and in turn, physicians can expand their ability to consult with and treat a higher volume of individuals.

As online care capabilities and frequency increase, so do the expectations for a rapid response time, which can significantly impact staff workflows within hospitals and medical office practices. Understandably, there is a rising demand for practitioners to be compensated for the time commitment to these online services.

It is permissible to bill for online communications and patient care. The U.S. Centers for Medicare and Medicaid Services (CMS) first introduced Medicare billing codes in 2019 that allowed providers to seek reimbursement for writing messages through secure portals. The pandemic prompted the agency to broaden coverage for telemedicine and allowed hospitals to significantly expand its overall use.² Insurance companies, taking their lead from Medicare, acknowledged the growth in online messaging and now also allow reimbursement for these consultations.

There are three evaluation and management (E/M) Current Procedural Terminology (CPT®) codes that distinguish time spent for responding to inquiries from patients. The three categories that can be billed for include online consultations according to the duration of time: 1) 5-to-10-minute duration, 2) 11-to-20-minute duration and 3) 20 plus minute duration.³ Depending on the patient’s insurance, they may be responsible for the entire charge of the “encounter,” or they may be responsible for a co-pay or coinsurance as they would for an office visit as dictated by their specific health plan. Organizations that are currently charging for online communication typically exclude Medi-Cal patients, but keep in mind, Medicare patients may still have to pay 20% of the charge per the Medicare breakdown.

Here are some of the finer details regarding billing for online communications:

Online digital E/M services can be reported when a provider performs appropriate E/M for an established patient and the services are differentiated by the amount of time spent over a period of seven days. The online interaction must provide the same services as an in-person or telemedicine interaction but by HIPAA compliant means, such as a secure online patient portal.

It is a true E/M service and must be performed in lieu of another visit.

The interaction must be medically necessary.

It is typically patient initiated in response to a new or worsening problem, but it is managed appropriately without needing a telemedicine or in-person interaction.

The interaction should include a medically appropriate history, a note about reviewing results and ordering testing, and the patient treatment performed.4

What activities are excluded from billing of online communications? Portal messages that are not true E/M services cannot be reported. For example, answering simple questions that take less than five minutes, communicating test results, calling in medication refills, changing medications due to cost or formulary, handling messages that do not require clinician expertise, and scheduling appointments do not qualify. If the online communication results in an in-person visit within seven days, the time or complexity of the portal message work is incorporated into the code selection of the in-person visit and the online service is not reported. One should not report these services if within a global period of a surgical procedure, unless unrelated to the procedure.5

Charging for online medical care and consultation services has many positive aspects. However, patients who previously used online communication to obtain medical advice and treatment with no associated cost may ask, “Why do I now have to pay for a service that I have been receiving for free?” This could produce feelings of dissatisfaction or discourage patients from seeking care as they did in the past due to a possible charge for the service.

If hospitals, clinics, and physician offices decide to charge for online communications, some risk management recommendations to consider are:

Set consistent parameters for what online service will be charged according to established and current guidelines. Consult with a medical billing and coding professional for clarification if needed.

Follow applicable insurance rules and regulations with respect to coding and submitting services for reimbursement or charging to avoid allegations of insurance fraud.

Inform patients up front about changes in policy to charge for online communications. Post information in a variety of locations so that patients are aware of potential charges and may read the provisions of your policies. Have patients acknowledge that they understand the prices and accept the terms and conditions.

Let patients know that it is permissible to charge for certain services based on the amount of time spent to provide the service and educate patients on what items they will not be charged for. Keep in mind, it may be difficult for patients to determine if an inquiry or request for service may represent a charge which may introduce an element of mystery to the mix. One way to address this would be to review the inquiry and if it meets the threshold for a charge, the patient could be notified of this and could be offered other options such as an in-person visit or a telehealth visit instead.

Educate staff about the policies and procedures related to charging for online communications in the provision of medical consultation and treatment.

Make it clear to patients when they should seek in-person medical care or care for an emergency medical condition (urgent or emergent care) and to not rely on online communication to communicate their health status and condition with an expectation it will be addressed online. Appropriate disclaimers should be used.

As the healthcare professional, use appropriate medical judgment and discernment. Do not attempt to treat a patient through online communication where standard of care or accepted medical practices indicate in-person consultation, treatment, or care is required.   


Bradford S. Dunkin is Assistant Vice President, Risk Management and Patient Safety. Questions or
comments related to this article should be directed

¹Emailing Your Doctor Could Soon Cost You, US News and World Report, February 2023

²Emailing Your Doctor May Carry a Fee, New York Times, January 24, 2023

³Be Careful When Charging for Patient Portal Messages, Urology Times Journal Vol 51 No 03, February 23, 2023

4Be Careful When Charging for Patient Portal Messages, Urology Times Journal Vol 51 No 03, February 23, 2023

5Emailing Your Doctor May Carry a Fee, New York Times, January 24, 2023


5Be Careful When Charging for Patient Portal Messages, Urology Times Journal Vol 51 No 03, February 23, 2023