Coding for Telemedicine Services During the COVID-19 Pandemic

Telemedicine has become an essential tool for physicians as they continue to provide care to their patients during the COVID-19 pandemic. In this article, which is the second of a 3-part series, we will discuss strategies for overcoming potential barriers to the implementation of telemedicine into a practice and the proper coding required so that urologists can be reimbursed for their services. Legal issues related to telemedicine will be covered in the third article.

Barriers to Telemedicine Implementation

Perhaps the most significant potential barrier to the adoption of telemedicine services are concerns regarding compensation for virtual health visits. The good news is that legislation in most states is supporting the expansion of these visits to assist patients who require routine care during the COVID-19 Public Health Emergency (PHE).

On March 17, 2020, the Centers for Medicare & Medicaid Services (CMS) expanded access to telehealth services to include all Medicare beneficiaries, not just those who have been diagnosed with the coronavirus.1 This permission to access telemedicine will certainly remain in effect for the duration of the COVID-19 crisis. In addition, the expanded access will apply to existing coverage from physicians’ offices, skilled nursing facilities, and hospitals. Medicare will now make payments to physicians for telehealth services that take place in any healthcare facility and in a patient’s home, so that individuals are not required to travel to their physician’s office for care. The rural and site limitations have been removed.2

Many physicians are uncertain as to whether they need to obtain a license to use telemedicine services with their patients. The March 10, 2020, guidance put forth by the CMS states that physicians who are licensed in the state where their patient resides do not require any additional license or permission to conduct virtual health visits. CMS has temporarily waived requirements that out-of-state providers be licensed in the state where they are providing services when they are licensed in another state. If urologists have questions regarding this issue, we suggest they contact their state Board of Medicine or Department of Health for up-to-date information on requirements for licenses across state lines.

As with any other aspect of providing care, urologists should use an informed consent form for all patients participating in telemedicine visits. Not only is obtaining informed patient consent a recommended best practice by the American Telemedicine Association in many states, it is also required by Medicare. Since telemedicine is new to most patients, it is important to explain to them how it works and what they should expect. How does patient confidentiality and privacy work with virtual visits? What types of technical equipment do patients need? What should they expect in terms of scheduling, cancellations, and billing policies?

Obtaining patient consent may be a legal requirement, depending on the state, or a condition of getting paid, depending on the payer. To determine what the requirements are in a particular state, physicians should consult The National Telehealth Policy Resource Center’s state map (see Sidebar). Some states do not have any requirements regarding consent for a virtual visit; others require verbal consent. Even if obtaining patient consent is not legally required in the state where the physician practices, it is still a good idea to consider making it a part of the practice’s policy for protection. In any case, it is wise to obtain either verbal or written consent and to document in a patient’s record that consent was obtained before initiating a virtual visit. The consent form should also include the practice’s policies regarding scheduling, cancellations, and billing with respect to telemedicine visits. The Agency for Healthcare Research and Quality has developed a sample consent form and guidance on how to obtain consent for telehealth services, which are available on its website.3

Sidebar

Resources for Additional Information Regarding Telehealth Policies

  • American Urological Association COVID-19 Info Center. Telehealth: www.auanet.org/covid-19-info-center/telemedicine
  • Center for Connected Health Policy. The National Telehealth Policy Resource Center’s state map: www.cchpca.org/telehealth-policy/current-state-laws-and-reimbursement-policies
  • Centers for Medicare & Medicaid Services (CMS). List of telehealth services: www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes
  • Center for Connected Health Policy. The National Telehealth Policy Resource Center. State Telehealth Laws & Reimbursement Policies: www.cchpca.org/sites/default/files/2019-10/50%20State%20Telehalth%20Laws%20and%20Reibmursement%20Policies%20Report%20Fall%202019%20FINAL.pdf
  • Federation of State Medical Boards. Telemedicine Policies: www.fsmb.org/siteassets/advocacy/key-issues/telemedicine_policies_by_state.pdf

Another potential barrier to virtual health adoption is concern over liability insurance for telemedicine services. Physicians who plan on offering these services to patients should request proof in writing from their insurance carrier that their policy covers telemedicine malpractice and that the coverage extends to other states, in case the patient resides in a state different from the one in which the provider holds a license. In addition, urologists should check with liability insurers for any requirements or limitations related to the use of telehealth services. Again, requirements or limitations should be documented. For example, a policy may require that the physician maintain a record—either written or entered in the patient’s electronic medical record—of the visit. Consequently, using Skype, Facebook, or Google to conduct virtual visits may not be ideal, since these applications do not allow for documentation, and therefore do not comply with malpractice liability requirements.

Certainly, concerns about privacy and Health Insurance Portability and Accountability Act (HIPAA) compliance are critical to the success of a telemedicine program. During the COVID-19 PHE, physicians may now use telehealth services to communicate with patients without any penalties being imposed.4 With these changes in HIPAA requirements, physicians may use applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype, to provide telehealth services without the risk that the Office for Civil Rights might impose a penalty for noncompliance with the HIPAA rules.

Some “public” applications may be associated with privacy risks; therefore, urologists should consider using programs that ensure encryption, privacy, and HIPAA compliance. It is also important to acknowledge that no virtual visit can offer complete privacy. It is helpful to remind patients, who may be in an office setting or in a home environment, that fellow employees or family members may be able to overhear conversations that occur during a virtual visit. Physicians can also suggest to patients that they schedule visits at a time and place that ensures the most privacy.

Coding for Telemedicine

Beginning January 1, 2020, CMS allowed Medicare Advantage plans to offer telehealth services as part of their basic benefits package without an additional fee for patients. CMS will now allow telemedicine as a standard, covered benefit in all plans, enabling beneficiaries to seek care in their homes rather than requiring them to go to a healthcare facility.5 In the past, telemedicine was restricted for use in rural areas or when patients resided a great distance from their providers. Beginning March 1, 2020, and for the duration of the COVID-19 crisis, Medicare will pay for professional services furnished to beneficiaries in all areas of the country in all settings, regardless of the location or the distance between the patient and the physician.1

The fact is that parity laws exist, and commercial payers and CMS are required by state law to reimburse for telemedicine—often at the same rate as that of a comparable in-person service. On the commercial side, an increase in commercial parity legislation has been reported, which requires health plans to cover virtual visits in the same way that they would cover face-to-face services. Given the new guidelines for reimbursement, certain states and Washington, DC, have parity laws in place.6

The Office of Inspector General will exercise enforcement discretion for reduced or waived cost-sharing for telehealth or other non–face-to-face services (virtual or e-visits) during the COVID-19 PHE. For Medicare claims, physicians should add modifier CS to indicate that cost-sharing will be waived.7

Virtual Visits

Medicare describes telehealth, telemedicine, and related terms as the exchange of medical information from one site to another through electronic communication to improve a patient’s health.1 These services can be provided in a variety of formats, including virtual visits, telephone calls, portal messages, and interprofessional consultations.

There are 4 main types of virtual health services that urologists can provide to their patients on Medicare: (1) Medicare telehealth visits, (2) virtual check-ins, (3) e-visits, and (4) telephone visits. Recommendations for reporting these types of virtual health services are detailed in Table 1.

Medicare Telehealth Visits

For Medicare telehealth visits, the provider must use an interactive audio and video telecommunication system that allows real-time communication between the distant site where the practitioner is located and the patient at home. This is referred to as synchronous communication.

These telehealth visits include the following Current Procedural Terminology (CPT) evaluation and management (E/M) codes:

  • CPT codes 99201-99205: Office or other outpatient visit for the E/M of a new patient
  • CPT codes 99211-99215: Office or other outpatient visit for the E/M of an established patient

CMS has relaxed the documentation requirements for these services during the COVID-19 crisis. Similar to in-person visits, documentation for virtual visits should meet billing criteria for new and established patient codes. Providers should indicate that the visit was conducted using a 2-way audiovisual device. There is no requirement or expectation that the encounter will be recorded or stored for later access. The policy allows office/outpatient E/M level selection (CPT codes 99201-99205, 99211-99215) when furnished via telehealth to be documented based on medical decision-making (MDM) or time.

Current definitions of MDM in the 1995 and 1997 Documentation Guidelines for E/M and time apply. Documentation of history and/or physical examination in the medical record is not required for MDM. Time is defined as all of the time associated with the E/M on the day of the encounter. This includes the time before the virtual visit commences plus the time of the actual virtual visit, as well as any time required after the virtual visit, which can be legally included in the time component.

For example, if a urologist spends 5 minutes preparing for a visit plus 15 minutes for a virtual visit, and an additional 5 minutes after the virtual visit has been concluded, it is appropriate to include in the documentation that 25 minutes were dedicated to the encounter. This example would qualify for a CPT code 99214 telehealth visit. The urologist should, however, document E/M visits as “necessary to ensure quality and continuity of care.”8

Important for Medicare: Place of Service (POS) Codes and Modifier Necessary for Telehealth visits:

  • From a patient’s home. If a patient is receiving a telehealth encounter by audiovisual communication from his or her home, Medicare is requiring the physicians to use the POS for those situations in which the encounter would have happened face to face, such as POS code 11 for office or POS code 23 for emergency department
  • Add modifier. Append modifier 95 Synchronous Telemedicine Service Rendered via Real-Time Interactive Audio and Video Telecommunications System to the visit code for Medicare claims
  • From an originating site. Use POS code 02 Telehealth for a typical Medicare telehealth encounter for those situations in which the patient would be advised to go to an originating site, such as the urologist’s office or to the hospital, to receive additional care
  • Commercial payers. Refer to their respective policies on reporting telehealth services, as different requirements may be in effect

The CMS has provided a list of all available codes for telehealth services on their website (see Sidebar).

Virtual Check-Ins

A virtual check-in occurs when a practitioner has a brief communication with a patient from his or her home via a number of communication technology modalities, including synchronous discussion over a telephone or exchange of information through video or images. Patients must agree to the service.

The following Healthcare Common Procedure Coding System (HCPCS) codes can be used if no medical visit took place within the past 7 days and a medical visit does not occur within the next 24 hours or the soonest available appointment:

  • HCPCS code G2012. Brief communication technology-based service—for example, virtual check-in by a physician or other qualified healthcare professional who can report E/M services
  • HCPCS code G2010. Remote evaluation of recorded video and/or images submitted by an established patient (eg, store and forward), including interpretation with follow-up within 24 business hours

E-Visits

E-visits are non–face-to-face communications between patients and providers through an online portal. These can be for either new or established patients but must be patient-initiated. Practices may educate beneficiaries on the availability of the service prior to initiation of the e-visit.

CPT codes for e-visits include the following:

  • CPT code 99421. Online digital E/M services, for an established patient; 5 to 10 minutes spent on the virtual visit
  • CPT code 99422. 11 to 20 minutes spent on the virtual visit
  • CPT code 99423. 21 minutes or more spent on the virtual visit

For Medicare, HCPCS codes include the following:

  • HCPCS code G2061. Qualified nonphysician healthcare professional online assessment, for an established patient; 5 to 10 minutes
  • HCPCS code G2062. 11 to 20 minutes
  • HCPCS code G2063. 21 minutes or more
  • For Commercial Insurers, CPT codes include the following:

    • CPT code 98970. Qualified nonphysician healthcare professional online digital E/M services, for an established patient; 5 to 10 minutes
    • CPT code 98971. 11 to 20 minutes
    • CPT code 98972. 21 minutes or more

    CPT codes for telephone-only visits (G2061-G2063, 99421-99423, 98970-98972) can be used if the following criteria are met: (1) The visit cannot originate from a related E/M service provided within the previous 7 days nor lead to an E/M service or procedure within the next 24 hours or the soonest available appointment. (2) The codes are reported based on the time spent by the healthcare professional speaking with the patient.

    Telephone Visits

    CMS is now allowing audio-only services for telephone assessments and management, or E/M services, between a practitioner and a patient. There are specific codes for providers who are allowed to report E/M services versus those who are not.

    • CPT code 98966. Telephone assessment and management services provided by a qualified nonphysician healthcare professional to an established patient; 5 to 10 minutes
    • CPT code 99867. 11 to 20 minutes
    • CPT code 99868. 21 to 30 minutes
    • CPT code 99441. Telephone E/M services by a physician or other qualified healthcare professional; 5 to 10 minutes
    • CPT code 99442. 11 to 20 minutes
    • CPT code 99443. 21 to 30 minutes

    CPT codes for telephone-only visits (98966-98968, 99441-99443) can be used if the following criteria are met: (1) The visit cannot originate from a related E/M service provided within the previous 7 days nor lead to an E/M service or procedure within the next 24 hours or the soonest available appointment. (2) The codes are reported based on the time spent by the healthcare professional speaking with the patient.

    Medicare has increased reimbursement for telephone visits CPT codes 99441-99443 comparable to CPT codes 99212-99214 during the COVID-19 PHE. CMS added 99441-99443 to the Medicare list of telehealth services for reimbursement starting March 1, 2020. To receive the outpatient E/M visit rates for telephone E/M codes 99441-99443, providers should bill the codes with modifier 95 and the same POS where the service would have taken place in person prior to the pandemic. For example, if the visit would have occurred at a physician’s office, POS 11 would be reported with modifier 95.

    What Are the Most Common CPT Codes Used in the Outpatient Setting?

    The answer to this question depends on several factors. A good rule of thumb is for physicians to use the same codes that they would use for an in-person appointment.

    For telemedicine services, in general, urologists would code as they would for any regular outpatient, face-to-face visit, using CPT codes 99211-99215 for an established patient visit and CPT codes 99201-99205 for a new patient visit. These are the most common CPT codes for outpatient urologic office visits, either as a face-to-face or a synchronous virtual visit, such as via a real-time interactive audio and video telecommunications system.

    As an example of a urologic encounter using telemedicine, the reimbursement for CPT code 99213 is approximately $76.15 (Medicare national reimbursement rate). But, how can you achieve the complexity requirements for a Level 3 office visit without performing a physical examination or completing a patient history? In response to the COVID-19 crisis, Medicare now allows office/outpatient E/M visits documented based on MDM or time. Documentation of a physical examination or patient history in the medical record is not required. The practitioner should, however, document E/M visits as necessary to ensure quality and continuity of care. The documentation requirement for face-to-face or virtual visits requires either: (1) Low complexity MDM or (2) At least 15 minutes spent treating the patient if coding is based on time.

    Time is defined as all of the time associated with the E/M on the day of the encounter. MDM requirements are shown in Tables 2 and 3.

    If a urologist reviews results of a recent laboratory test for a patient with benign prostatic hyperplasia, adjusts the alpha-blocker dosage, and writes a prescription, this encounter meets the MDM requirements for CPT code 99213. If a urologist spends a total of 15 minutes, which includes preparing for the encounter before the visit, spending time with the patient, and the time spent after the visit, this visit would meet the time requirement for CPT code 99213. Level 4 (CPT code 99214) requires moderate complexity MDM, and Level 5 (CPT code 99215) requires high complexity MDM or documenting the total time spent preparing for the encounter, the time spent with the patient, and the time spent after the encounter (ie, CPT code 99214 requires 25-39 minutes of consultation, and CPT code 99215 requires ≥40 minutes of consultation).

    Conclusion

    It is evident that telemedicine is here to stay. Urologists who are not willing to use these services will soon discover that the number of patients in their practices are decreasing signficantly. This is not to suggest that in-person interactions are going to disappear completely, because nothing can replace the value of a trustworthy, well-respected, face-to-face visit. However, we also need to be prepared for a seismic shift to telemedicine in the not-too-distant future.

    References

    1. Centers for Medicare & Medicaid Services (CMS). Medicare telemedicine health care provider fact sheet. March 17, 2020. www.cms.gov/newsroom/fact-sheets/medicaretelemedicinehealthcareproviderfactsheet. Accessed April 23, 2020.
    2. Centers for Medicare & Medicaid Services (CMS). CMS issues guidance to help Medicare Advantage and Part D plans respond to COVID-19 [press release]. March 10, 2020. www.cms.gov/newsroom/press-releases/cms-issues-guidance-help-medicare-advantage-and-part-d-plans-respond-covid-19. Accessed April 23, 2020.
    3. Agency for Healthcare Research and Quality. How to Obtain Consent for Telehealth. www.ahrq.gov/health-literacy/obtain-consent-telehealth.html. Accessed May 21, 2020.
    4. U.S. Department of Health & Human Services (HHS). Notification of enforcement discretion for telehealth remote communications during the COVID-19 nationwide public health emergency. March 30, 2020. www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html. Accessed April 23, 2020.
    5. Centers for Medicare & Medicaid Services. List of telehealth services. Updated April 30, 2020. www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes. Accessed April 20, 2020.
    6. Center for Connected Health Policy. The National Telehealth Policy Resource Center. Current state laws & reimbursement policies. www.cchpca.org/telehealth-policy/current-state-laws-and-reimbursement-policies. Accessed April 20, 2020.
    7. U.S. Department of Health and Human Services (HHS). Office of Inspector General (OIG). HHS OIG policy statement on practitioners that reduce, waive amounts owed by beneficiaries for telehealth services during the COVID-19 outbreak. https://oig.hhs.gov/fraud/docs/alertsandbulletins/2020/factsheet-telehealth-2020.pdf. Accessed April 20, 2020.
    8. American Urological Association. Frequently asked questions on telehealth/telemedicine. www.auanet.org/Documents/advocacy/advocacy-by-topic/AUA-FAQs%20-Telehealth.pdf. Accessed May 10, 2020.

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