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Cosmos Study

Telehealth Visits Frequently Billed at Lower Level of Service Than Office Visits

September 12, 2023
Dual-Team Study
Team A:Jackie Gerhart, MDAlex Piff 
Team B:Kersten Bartelt, RNEric Barkley

Key Findings

  • For both primary and specialty care, telehealth visits are more frequently coded with a lower level-of-service billing code than in-person office visits of the same specialty. 

Some studies have suggested that telehealth visits are more often used for chronic disease management, existing patient follow-up, and medication management, which are typically considered less complex visits than new patient visits or visits that require a physical assessment.1  

To better understand the level of care provided through telehealth versus office visits, we evaluated the level-of-service (LOS) billing codes for 1,313,724 telehealth visits and 5,254,896 office visits from January 1, 2022, through June 30, 2023. Higher LOS codes represent more complex patient encounters, with LOS 1 being the least complex and LOS 5 the most complex.2 We matched patients in the telehealth cohort to patients in the office visit cohort by age, sex, race, ethnicity, social vulnerability index (SVI), census region, rural or urban area, specialty, chief complaint, and whether the patient was a new or established patient. 

For primary care, we found that across both telehealth and office visits, visits coded with an LOS of 3 or 4 were the most common. However, more than half (53.7%) of primary care telehealth visits for established patients were coded at LOS 3 compared to 43.3% of primary care office visits. Conversely, 40.8% of primary care telehealth visits were coded at LOS 4, while more than half (52.5%) of primary care office visits for established patients were coded at LOS 4, as shown in Figure 1.  

For specialty care, we found that both telehealth and office visits for established patients were coded at LOS 4 most frequently. Our analysis found 64.1% of specialty office visits were coded at LOS 4 or 5, compared to 56.8% of specialty telehealth visits. We saw similar trends in new patient telehealth and office visits for both primary and specialty care.  

Figure 1
Level-of-Service Codes for Telehealth and Office Visits by Type of Care
Level-of-Service Codes for Telehealth and Office Visits by Type of Care
Figure 1. Proportion of telehealth and office visits with each LOS billing code stratified by established or new patient and primary or specialty care.

Telehealth visits were, on average, consistently billed at a lower level of service than office visits of the same type, with one exception. New patient specialty telehealth visits were billed at LOS 5 slightly more frequently than office visits of the same type. However, patients might self-select into an in-person office visit if they feel they need a higher level of care, or the proximity of additional tests, services, and providers in an office setting might help a provider facilitate additional assessment that might increase the level of service provided during the visit. Additional research is needed to assess whether these or other factors might contribute to these differences. 

These data come from Cosmos, a HIPAA-defined Limited Data Set of more than 214 million patients from 218 Epic organizations including 1,235 hospitals and more than 26,800 clinics, serving patients in all 50 states and Lebanon. This study was completed by two teams that worked independently, each composed of a clinician and research scientists. The two teams came to similar conclusions. Graphics by Brian Olson. 

References

  1. Ward K, Vagholkar S, Sakur F, Khatri NN, Lau AYS. Visit Types in Primary Care with Telehealth Use During the COVID-19 Pandemic: Systematic Review. JMIR Med Inform. 2022;10(11):e40469. Published 2022 Nov 28. doi:10.2196/40469 
  2. American Medical Association. Evaluation and Management (E/M) Service Guidelines. https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf. Accessed August 11, 2023.