Get paid for telehealth & non-face-to-face visits during COVID-19

On our most recent webinar, Getting paid for Telehealth & non-face-to-face visits during COVID-19, Caroline Balestra, Business Process Analyst at Health Prime, reviewed telehealth, phone visits, and other important types of service visits covered during a public health emergency such as COVID-19.

Telehealth is different from telemedicine in that it refers to a broader scope of remote healthcare services than telemedicine. However, the industry has been using Telehealth and Telemedicine interchangeably as synonymous terms since their widespread adoption, making any distinction between them obsolete.

Public Health Emergency (PHE) – Waiver 1135

The Secretary of Health and Human Services (HHS) may temporarily waive or modify certain Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) requirements to ensure sufficient healthcare items are available to meet the needs of individuals enrolled in Social Security Act programs in the emergency area and time periods.

Providers who give such services in good faith can also receive reimbursement and exemption from sanctions as long as there is no determination of fraud or abuse.

There are TWO requirements:

1.  The president must have first declared an emergency or disaster under either the Stafford act or the national emergencies act.
2.  The Secretary must have declared a public health emergency under section 319 of the Public Health Service Act.

Since the Social Security Act makes these exceptions for Medicare, commercial payers do not have to follow them. Private payers can also cooperate, but there is no requirement to do so.

From March 6^th, 2020, through the duration of the PHE:

Medicare Advantage is not Medicare!

Medicare Advantage plans must offer beneficiaries at least the same benefits they receive from regular fee-for-service Medicare, but they function as commercial, private payers. Some will follow FFS Medicare in this, others will be more liberal in their coverage. It’s important that you understand the requirements for the specific commercial Medicare Advantage plan you are working with.

What are some questions you can ask commercial payers related to telehealth coverage?

“It is essential that you ask some important questions to commercial payers so you can understand the benefit the patient plan offers. Understanding the plan benefits will allow for correct coding, submission and will help to ensure your payment for services” – Balestra explained.

Some questions you can ask yourself are:

• What are the effective dates?
• What services are covered?
• May these services be provided by Nurse Practitioners, Physician Assistants, and other Qualified Healthcare Providers (QHP)?
• How are those to be billed?
• Do we use telehealth codes or office visit codes?
• What place of service?
• What modifiers are necessary?
• Is this only for services related to COVID-19?

Some important things you need to know:

• Even during PHE, telehealth requires real-time audio and video.
• Providers must use only the services on the telehealth code list and meet all criteria for each CPT.
• The new guidance from CMS states that the provider can choose to use whichever POS is most appropriate and can also apply a -95 modifier when applicable.
• Other services now payable, such as virtual check-in, online services, and telephone calls, are not telehealth. They are CTBS (Communication Technology Based Services).

What are some common modifiers for Telehealth?

• Modifiers 95: Synchronous telemedicine service that must be a live audio-video linkage connection. It cannot be “stored and forwarded” and can be used in lieu of place of service 02.
• GQ: Asynchronous telecommunications system only for patients in Alaska or Hawaii.
• GT: Via interactive audio and video telecommunications system.
• GO: used for telemedicine for symptoms of acute stroke.

The CMS stated that a modifier is not necessary when using POS 2, but some contractors and payers want you to use the modifier CR for catastrophe or disaster-related services.

What happens with the CPT coding in telehealth?

Medicare has outlined that the Evaluation and Management (E/M) level selection for telehealth services can be based on MDM (Medical Decision Making) or time.

Medical professionals can use new or established CPT codes and will no longer require the components that reference typical face-to-face time. Each service includes a medically appropriate history and/or examination. Then, the code selection will be based on the MDM level or total time spent on that date of the encounter. 

Time documentation is a requirement with this new rule. Activities included are preparing to see the patient, performing the exam, counseling or educating the patient, caregiver, or family, ordering medications or testing, and care coordination.

“How can I document an exam without laying hands on the patient?” It is possible to perform an exam just by observing and talking with a patient during a real-time audio and video conference. You can analyze general appearance, sclera anicteric injected, hearing intact, skin tone, respiratory effort, gait and station, mental status, and more,” Balestra said.

Ensure that your documentation is complete based on your MDM. This includes establishing a diagnosis, assessing the status of a condition, and/or selecting a management option.

If you would like to review what is included on MDM and know more about the E/M Coding changes for 2021, read our What’s changing for E/M codes this 2021 blog.

Private and other Payers

What happens in hospitals and nursing facilities?

Interprofessional Internet Consultation

This type of consultation is NOT telehealth.

CMS recognizes and pays for interprofessional consults codes 99446 through 99449 and codes 99451 and 99452.

Specific CPT codes may have certain requirements, including a written and/or verbal report to the requesting physician. You can bill with these CPT codes, but not as a telehealth visit. You would have to use the appropriate place of service, but -02 is not allowed for these services as it represents telehealth.            

Let’s review some non-face-to-face visits that you need to consider:

For all visits not related to COVID, you will document and code as normal. According to the Diagnosis Coding Guidelines, you must code all documented conditions that coexist at the time of the encounter, and require or affect patient care, treatment, or management.

Effective April 1st, 2020, you have to use ICD10 codes for:

• U07.1 Virus identified and confirmed COVID-19.
• U07.2 COVID-19, virus not identified is assigned to a clinical or epidemiological diagnosis of COVID-19 where laboratory confirmation is inconclusive or not available.
  *U07.1 and U07.2 may be used for mortality coding as cause of death.

For suspected cases, code the symptoms or reason to suspect as: 

• Z20.828 Contact with and (suspected) exposure to other viral communicable diseases.
• R05 Cough
• R50.9 Fever

It is important that you look at the guidelines for each payer. Don’t assume that they are the same as CMS. Remember to fulfill the documentation requirements of the code used and document all diagnosis codes at each encounter. Store your encounter information where the provider and payer can access it if a review is needed.

If you have any questions or want more information, feel free to contact us at [email protected]. Subscribe to our Health Prime blog to stay tuned to our upcoming webinars and all the latest updates to run your medical practice better so you can focus on what matters the most: your patients.