Coding Telehealth/Telemedicine COVID-19 (Updated Aug 13, 2020)
Post written by Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA Approved ICD-10- CM/PCS Trainer.
UPDATED AUGUST 13, 2020
Understanding Telehealth and Telemedicine has risen to a new, greater level of importance and need since the COVID-19 pandemic. The terms “Telehealth” and “Telemedicine” are inter-related which generally refers to the exchange of medical information from one site to another through electronic communication to improve a patient’s health (per CMS). Due to the COVID-19 pandemic and the declared Public Health Emergency (PHE) the Centers for Medicare and Medicaid Services (CMS) released “Waiver 1135”, which broadened access to Medicare telehealth services so that beneficiaries can receive a wider range of services from their doctors without having to travel to a healthcare facility. This waiver also helps allow providers to bill for these services and receive some payment. The “waiver” has been updated several times since the PHE was declared, so staying informed is very important and it remains in place until the PHE is declared ended.
In addition to CMS, the American Medical Association (AMA) has published additional information and guidance regarding telehealth and the appropriate documentation and codes to use in response to the COVID-19 PHE.
Telehealth/Telemedicine covers a continuum of technologies that offer new ways to deliver care and even monitor the patient in some situations including:
Real-time, audio-video communication tools (telehealth) that connect physicians and patients in different locations.
Store-and-forward technologies that collect images and data to be transmitted and interpreted later.
Remote patient-monitoring tools such as blood pressure monitors, Bluetooth-enabled digital scales and other wearable devices that can communicate biometric data for review (which may involve the use of mHealth apps).
Verbal/Audio-only and virtual check-ins via patient portals, messaging technologies, etc.
Key documentation elements for Telehealth services include the following:
Specific documented statement of why the telehealth is necessary to conduct via an electronic media instead of in a medical setting (hospital or clinic)
Describe/document the specific type of Electronic Media or program being used, such as phone, texting, Skype, FaceTime, Zoom, GoToMeeting, etc.)
There needs to be documentation of patient consent to use the electronic media.
Document the “TIME”: Many payers are requiring the start and end time, plus total time for telehealth visits.
Provide the current diagnosis, including “Chronic Conditions” i.e., heart disease, diabetes, lung disease (COPD, Asthma), cancer, and/or immunocompromised. These diagnoses can help to justify the medical necessity for telehealth services.
It is important to know that during the COVID-19 pandemic PHE that:
we can use both New and/or Established patient visit types.
these telehealth/telemedicine codes are intended for physicians and midlevel providers.
Under the PHE CMS is also allowing, Physical Therapist, Occupational Therapist, Speech and Language Pathologist to provide telehealth/telemedicine services. In addition, telehealth services performed by auxiliary personnel who cannot independently bill Medicare for their services, such as respiratory therapists, can be furnished and billed incident to the services of an eligible billing practitioner.
CMS recently updated their FAQ and stated the following: During the PHE, the availability of HCPCS codes G2010 and G2012 is broadened to allow certain practitioners, such as physical therapists, occupational therapists, speech language pathologists, licensed clinical social workers, and clinical psychologists, who do not report E/M codes to bill for these services. CMS has also activated CPT codes 98966, 98967, and 98968, which describe assessment and management services conducted over the phone.
Hospitals do not bill for Medicare telehealth services. However, if a hospital employs certain practitioners who are not authorized to independently bill Medicare for their services, such as respiratory therapists, the hospital may bill for the outpatient hospital services provided by that staff using telecommunications technology.
the telehealth/telemedicine codes can not be originating or related to an E&M done within the last 7 days.
the telehealth/telemedicine codes are not leading to an E&M in the next 24 hours or soonest available.
if the services are related to a global (OB, Surgery, Fracture) they cannot be billed separately or outside the global period.
There are three main types of virtual services physicians and other professionals can provide to Medicare beneficiaries:
Medicare telehealth visits
Virtual check-ins
E-visits.
Effective for services starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency (PHE), Medicare will make payment for Medicare telehealth services furnished to beneficiaries in any healthcare facility and in their home.
Virtual Check-Ins: Looking back we see that in 2019, Medicare started making payment for brief communications or Virtual Check-Ins, which are short patient-initiated communications with a healthcare practitioner. There are two G codes that should be used for these virtual check-ins; and remember the following:
5 to 10 Minutes of Medical Discussion
Do not have geographic or site restrictions
Reimbursement amounts are low as these are only for quick check-ins
NOTE: Must document time spent or will not be allowed.
G2012 Brief communication, Technology based
G2010 Remote evaluation of recorded video and/or images with interpretation and follow-up with the patient within 24 hours.
Medicare Part B does separately pay clinicians for E-visits, which are non-face-to-face patient-initiated communications through an online patient portal. Many healthcare organizations provide a patient portal through the establishment of the electronic health record (EHR).
Beginning MARCH 30th, 2020 CMS allowed more than 80 additional services to be furnished via telehealth. During the public health emergencies, individuals can use interactive apps with audio and video capabilities to visit with their clinician for an even broader range of services. Providers also can evaluate beneficiaries who have audio phones only.
Prior to the PHE the most common telemedicine services/codes used were for office or other outpatient evaluation and management (E/M) codes CPT 99201 – 99205 New patient visit; CPT 99212 – 99215 Established patient visits; CPT 99241 – 99245 Consultation codes; and CPT 99406 – 99408 Behavioral change intervention codes.
The American Medical Association (AMA) coding updates regarding telehealth services during the HE is as follows.
The CPT™ codes 99441, 99442 and 99443 are for “Telephone” visits in time increments of 5 to 10 minutes, 11 to 20 minutes and ≥ 21 minutes.
CPT Codes for online digital services for “Texting and Emails” are: 99421, 99422, 994223”, these are also in time increments of 5 to 10 minutes, 11 to 20 minutes and ≥ 21 minutes, respectively. (refer to your CPT codebook for the descriptions)
The AMA has the complete list of CPT codes covered under the waiver (PHE) at:
NOTE: The E&M code selected would be what would have been provided had this service/encounter been an inter-active face-to-face encounter. (ELECTRONIC face-to-face.)
Telehealth modifiers are required and include the following:
CR: Catastrophe / Disaster Related (not required during the PHE)
-95: Synchronous Telemedicine Services Rendered Via A Real-Time Interactive Audio and Video Telecommunications Systems: This is a real time interaction via telecommunication systems where the physician can see the patient and allows interaction. The codes that this modifier can be appended to are listed in Appendix P.
-GT: Via Interactive Audio and Video Telecommunication Systems: This is a real time interaction via telecommunication systems where the physician can see the patient and allows interaction
-GQ: Via Asynchronous Telecommunications Systems: Does not take place in real time and would likely not involve E&M services. Involves storage of the electronic interaction.
Place of Service (POS) Code is usually “02”, BUT under the PHE Waiver 1135, you should assign the POS code that would have been reported had the service been furnished in person.
For a complete list of the CMS telehealth codes included in the PHE waiver go to: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes
The following insert showing a partial portion of the CMS list (excel file) which includes the CPT codes and descriptions, PHE Status, a column for “Can Audio-only Interaction Meet the Requirements?” and a column for “Medicare Payment Limitations”, not only for physician services but also Psy Trmt, ESRD, Physical Therapy, Occupational Therapy and Speech Therapy services, and others, plus there are several G codes included. Here is an example of the listing:
Remote Patient Monitoring or RPM is another form of telehealth that we are seeing more and more. This patient monitoring devices can send vital and other important patient data and/or disease information to the physician remotely (i.e., Blood Pressure reading, Blood Glucose reading). CPT© codes for the provision of RPM includes:
CPT Code 99453: Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment. (Initial set-up and patient education of monitoring equipment) - Do not report 99453 for monitoring of less than 16 days
CPT Code 99454: Device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days. (Initial collection, transmission, and report/summary services to the clinician managing the patient)
CPT Code 99457: Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes
CPT Code 99458: Each additional 20 minutes (List separately in addition to code for primary procedure)
CPT Code 99091: Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/ regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days.
CMS does provide reimbursement for code 99453 (approx. $20.00) which is for the initial set-up and patient education on how to use the monitoring equipment. Reimbursement is also provided for CPT code 99454 (approx. $64.00) which is for supplying the device over a 30-day period.
The Centers for Medicare & Medicaid Services announced within the waiver… allowing doctors to furnish telehealth and other services using communications technology wherever the patient is located, including at home, even across state lines. However, practicing across state lines is subject to requirements set by the states involved.
Health care providers may offer telehealth services to patients located in their homes and outside of designated rural areas. For the duration of the COVID-19 PHE, the Centers for Medicare & Medicaid Services will reimburse telehealth visits in lieu of many in-person appointments.
CMS has stated that “covered health care providers that seek additional privacy protections should use technology vendors that are HIPAA compliant and will enter into HIPAA business associate agreements (BAA) in connection with the provision of their video communication products.” Thus, we need to ensure that we are meeting HIPAA requirements when using telemedicine devices.
With the increases in the frequency of telehealth services during the PHE we are now hearing that CMS may make some of the waiver changes permanent, so stay tuned on this CMS decision.
Due to the COVID-19 pandemic PHE, there are changes, additions, and revisions to the acceptable codes for telemedicine. In addition, CMS has made some policy changes so it is critical to check published memorandums, fact sheets and other CMS communications regularly. Staying informed is vital for accurate and compliant coding and for revenue cycle integrity to be achieved.
References: https://telehealth.hhs.gov/providers/policy-changes-during-the-covid-19-public-health-emergency/#:~:text=The%20Centers%20for%20Medicare%20%26%20Medicaid%20Services%20announced,subject%20to%20requirements%20set%20by%20the%20states%20involved.; https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes; https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet; https://www.ama-assn.org/topics/telemedicine; https://www.ama-assn.org/system/files/2020-05/telehealth-services-covered-by-Medicare-and-included-in-CPT-code-set.pdf; https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf