A patient sends a message to a physician using the practice's secure patient portal requesting a refill of their levothyroxine. The patient was seen for a routine exam in the office 10 days ago but forgot to request the refill at that time. The physician reviews the patient's records and notes that the patient did have their TSH, T3, and T4 levels checked at that visit, and that the results are stable, indicating that the patient should continue their current dose of levothyroxine. The physician submits a refill of the levothyroxine electronically to the patient's pharmacy and responds to the patient through the patient portal, letting them know that their lab results are stable, and that the medication refill has been submitted to the pharmacy. The physician spent 15 minutes reviewing the patient's chart, submitting the prescription, and responding to the patient in the portal. There is no further discussion with the patient via the portal over the next 7 days. Would CPT code 98016 or CPT code 99422 be the most appropriate code to report? ...

Subscribe or sign in to view the full article.

Sign In Subscribe Today

Note:  The following article synopsis was NOT provided by the AMA. It was created by Find-A-Code/innoviHealth.

Article Overview

This article explains a coding scenario involving a patient-initiated secure portal message to a physician, with related chart review, prescription handling, and follow-up messaging. It is aimed at coding professionals and clinicians who need to understand the distinctions between digital E/M services and brief communication technology-based services. The discussion focuses on the service setting, timing, and general reporting considerations for the encounter.

Why This Topic Matters

Accurate classification of portal-based interactions affects compliant CPT reporting for remote patient communication and physician work performed outside an office visit.

Codes Discussed

• CPT: 98016
• CPT: 99422

Subscribe or sign in to view the full article.

Sign In Subscribe Today