by Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, COC
KGG Coding and Reimbursement Consulting, LLC
Most experts expect Centers for Medicare & Medicaid Services (CMS) to ease restrictions on coding and billing of telehealth services. While new information is being published almost daily, as of 3/17/2020 at 10:00 a.m., we do not have any regulations from CMS easing the telehealth restrictions. A press release from March 10 outlines flexibilities that include waving cost-sharing for COVID-19 treatment in doctor’s office or emergency rooms and services delivered via telehealth.
Other payers have done so, and I will note examples of those below. Requirements will vary by payer, and unfortunately, providers will need to communicate with each individual payer for guidance on those patients. This is true also of Medicare Advantage plans. The language in the press release (March 5, 2020) for coverage by Medicare Advantage (MA) plans uses terms such as “may provide” and “it is possible that MA plans can receive clinically appropriate services.” This policy statement opens the door for individual plans to make the final decision.
For fee-for-service, traditional Medicare
Until and unless telehealth originating site restrictions are eased, your options for coding of telehealth services are two:
- G2012 – 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 E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
- G2010 – Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment
Please note the following restrictions:
- Established patients only (same definition as for other E&M services)
- Verbal consent required and must be documented in the patient’s medical record
- No service-specific documentation requirements but medical necessity must be documented.
- May only be billed by those providers who can perform and bill E&M services
For email or portal communication
We also have these new codes for 2020:
- #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 – …11-20 minutes
- #99423 – … 21 or more minutes
Please note the following restrictions:
- Patient-initiated digital communications requiring a clinical decision that would otherwise be made during an office visit
- Physician/Qualified Healthcare Professional (QHP) time only
- Not billable if patient seen in person or through telehealth within 7 day period
Check with Your Insurer
I recommend checking with the applicable insurer for the most up-to-date information affecting requirements for coding and billing of telehealth services. A few things to ask about:
- What are the effective dates? Most insurers are limiting this exemption to a specific period of time.
- What services are covered?
- How are those to be billed?
- Do we use telehealth codes or office visit codes?
- What place of service?
- What modifiers are necessary?
Here are examples of how some insurers are dealing with this increased demand for telehealth:
United Health Care is waiving originating site restrictions for their commercial, Medicare Advantage, and Medicaid plans. The patient may be at home or at another location. All the other requirements for telehealth must be met. These include the place of service 02 and the GQ (asynchronous telecommunications system) or GT (interactive audio and video telecommunication system) modifier. This waiver is only in effect until April 30, 2020.
United Health Care’s “Provider Telehealth Policies” (March 14, 2020) are available here: https://www.uhcprovider.com/en/resource-library/news/provider-telehealth-policies.html
Blue Cross Blue Shield of Alabama is allowing providers to bill for phone call treatment of existing patients under the established patient office visit codes. They are allowing codes up to 99213 but many providers are concerned about reaching that level of service when no examination can be performed. Remember that established patient office visits require only two of the three key components – history, examination, medical decision-making. If the physician documents an expanded problem-focused history and low complexity medical decision-making, 99213 will be supported.
For example, the patient calls in with complaint of dysuria. The physician documents the complaint (Duration, Timing) and further asks questions about fever, nausea and vomiting (Constitutional and Gastrointestinal Review of Systems). He also reviews the patient’s Past Medical History and Allergies. Based on her previous history, he suspects that the patient has a urinary tract infection and orders an antibiotic. These services will be billed with place of service 02 for telehealth.
The key point is that the physician himself must have the conversation with the patient on the phone. This may be something that a nurse may have handled previously, but now it must be performed by the physician to be billable. For example, a patient with asthma calls in with an exacerbation – the physician can actually hear the patient wheezing over the telephone – that would be documented as a problem-focused examination. BCBS of Alabama is currently limiting this to services through April 16, 2020.
Blue Cross Blue Shield of Alabama’s “Coronavirus: Provider Updates (March 13, 2020) is available here: https://providers.bcbsal.org/portal/web/pa/resources/-/resource/viewArticle/XBPIOOAUGB?frm=alabamablue.com
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About the Author:
Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, COC; KGG Coding and Reimbursement Consulting, LLC
Kim Huey is an independent coding and reimbursement consultant, providing audit, training and oversight of coding and reimbursement functions for physicians. Kim completed three years of pre-medical education at the University of Alabama before she decided that she preferred the business side of medicine. She completed a Bachelor’s degree in Health Care Management and went on to obtain certification through AAPC and AHIMA. Recognizing the important position of compliance in today’s environment, she has obtained certification as a Certified Professional Compliance Officer and has earned a Master of Jurisprudence in Health Law. Kim has authored numerous articles, spoken at local, state and national conferences and presented audioconferences related to the business side of medicine. Kim has worked with providers in virtually all specialties, from General Surgery to Obstetrics/Gynecology to Oncology to Internal Medicine and beyond. Kim can be reached at [email protected]