Ensuring accurate coding and billing for patient portal messages as e-visits

Patients increasingly contact their physicians and practice staff through digital portals for brief inquiries regarding ordering tests, prescription management, questions about new or unrelated problems, or any straightforward healthcare inquiry.

A Jan. 28, 2025, MGMA Stat poll finds that seven out of 10 (70%) of medical groups reported an increase in patient portal message volume in 2024, while 29% noted volume was about the same and only 1% reported a decrease in portal messages. The poll had 223 applicable responses.

Since 2019, use of patient portal messaging to contact physicians for non-urgent matters surged as COVID-19 pandemic limits on in-person visits shifted more patients to telehealth, though some elements of portal use have ebbed in the years since as many practices returned to normalcy.

To address this growing reliance on digital communication, CMS has updated billing policies, enabling physicians to bill for secure patient portal messaging. This shift also led to the introduction of new CPT^® codes for “e-visits,” allowing practices to capture revenue for these services:

• 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

Additionally, HCPCS code G2012 has been deleted and replaced by CPT ^® code 98016, defined as:

Brief communication technology-based service (e.g., virtual check-in) by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related evaluation and management service provided within the previous 7 days nor leading to an evaluation and management service or procedure within the next 24 hours or soonest available appointment, 5-10 minutes of medical discussion.

These codes allow providers to bill for longer e-visit consultations conducted through secure patient portals or other digital platforms. Key requirements include:

• An established patient-provider relationship
• Adherence to specific documentation standards that meets payer criteria
• Time-based billing for asynchronous digital evaluation initiated by patients over a seven-day period per clinical episode.

While patient portal messaging increases convenience and fosters engagement, practices must establish clear policies for appropriate use. These policies should address:

• Obtaining patient consent for e-visits
• Applying clinical judgment
• Thorough documentation in the portal message
• Adherence to payer-specific rules.

What are the impacts?

As many medical groups try to determine if they should bill for messages, there are several potential impacts on patient engagement to consider. Charging for messaging could reduce message volume due to the hesitation to communicate, but that may lead to missed opportunities for early intervention or health education.

If charges deter patients from using portals, it may reduce the convenience factor that portals offer, which could impact patient satisfaction and retention. Patients may start calling the practice instead, which would add to call volume and another concern that would need to be addressed. Messaging is often accepted at practices with value-based agreements, as it aligns with comprehensive patient care approaches.

In a study of billing eligible patient-initiated portal messages as e-visits, researchers at the Mayo Clinic found an 8.8% decrease in the volume of portal message threads over a six-month period of billing compared to the same period the previous year. As the authors note, the use of a pop-up disclaimer alerting patients of the potential of an e-visit bill may have influenced the shift in volume, and providers — though wary of increased workload — were mostly accepting of the move to bill for e-visits.

Charging for portal messages could also impact the use of telehealth services. There may be a shift to video visits as they may perceive more value in a face-to-face interaction if they have to pay.  There is a risk that charging for messages could disproportionately affect lower-income patients, potentially reducing their access to both messaging and telehealth services.

Healthcare systems might want to focus on more integrated approaches to telehealth, combining messaging, video visits, and other digital health tools into comprehensive care packages.

Roles to help with the burden of messages

Several clinical roles could help manage the workload of patient portal messages and phone calls to relieve providers:

• Nurse practitioners (NPs) can handle many routine inquiries and provide medical advice within their scope of practice.
• Physician assistants (PAs) can address many patient concerns and questions.
• Registered nurses (RNs) can triage messages, answer general health questions, and escalate complex issues to providers.
• Clinical pharmacists can manage medication-related inquiries and provide patient education on drug interactions and side effects.
• Care coordinators can handle non-clinical questions about appointments, referrals, and care plans.
• Medical assistants can manage routine administrative tasks and simple clinical inquiries under provider supervision.
• Health coaches can address lifestyle and wellness-related questions, supporting chronic disease management.
• Patient navigators can guide patients through the healthcare system, answering questions about processes and resources.

Key aspects of successful models include:

• Selective billing: Only charging for messages requiring medical expertise and taking significant time (typically five minutes or longer)
• Tiered pricing: Adjusting costs based on insurance coverage
• Clear communication: Informing patients about which types of messages may incur charges
• Low frequency: Billing for a small percentage of total messages (often less than 1%)

It is important to consider how charging for portal messages may negatively impact patient satisfaction and retention and patient care and look for ways to relieve the burden of those messages by using other staff to help offset the burden for the providers.

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