Coding Strategy - Telehealth
Michele Godges, VP Revenue Cycle|Medical Specialties Managers, Inc.
Coverage for telehealth services has gone through rapid changes due to the COVID-19 emergency.Deployment and optimization of a telehealth strategy is critical to serving your patient base during this crisis. Payers have deployed a variety of policies that allow most evaluation and management (E/M), screening and wellness services to be performed and paid when performed via telehealth. This document is meant to offer guidance on how to accurately report services delivered via telehealth and optimize your revenue.
- Services must be initiated by the patient.
- Must document patient consent for Telehealth visit.
- Telehealth service should include the modifier -95 when code is not inherently telehealth.
- Medicare E/M services (99201-99215) should be billed with POS 11 with -95 modifier to get full non-facility reimbursement.
- Estimated pricing below is based on current Orange County/LA locality.
Video and Audio
- Smart phones with audio/video (facetime) are acceptable.
- Does not need to be a HIPAA approved vendor but not Facebook Live, TikTok or other public facing solutions.
- 99201-99205 – new patient
- 99211-99215 – established patient
- Documentation should support time-based coding.
- Include a statement in report “Greater than 50% of this visit was spent in counseling patient on _____”
- Select code based on total time spent with patient.
- These codes are used to report direct, face-to-face patient contact for an unusually long period of time rendered by a physician or other qualified healthcare professional
- Ensure that total time is documented to meet these thresholds.
- Work done before or after a patient visit can be reported when cumulative you spend 30 additional minutes on patient coordination of care using code 99358.
- 99358 does not need to occur on the same date of service as a patient visit.
- Documentation does need to illustrate total time spent and outline what activities took place.
- For counseling visits, max out time-based coding of code set before using prolonged services.
Add-on Codes During a Telehealth visit
- The documentation in the medical record must support the billing of the cessation code. The documentation needs to record what was discussed during counseling and should show a significant and separately identifiable service.Document the amount of time spent counseling patient
- Items to document may include to following elements:
- The patient’s tobacco use
- Advised to quit and impact of smoking
- Assessed willingness to attempt to quit
- Providing methods and skills for cessation
- Medication management of smoking session drugs
- Resources provided
- Setting quit date
- Follow-up arranged
Intensive Behavioral Counseling for obesity, 15 mins
- Intensive behavioral intervention for obesity should follow the 5A’s approach adopted by the USPSTF: assess, advise, agree, assist, and arrange.
- Must have a diagnosis of BMI of 30.0 or over.
Alcohol Screening and Counseling
- Medicare covers annual alcohol screening and up to four, brief face-to-face behavioral counseling sessions per year to reduce alcohol misuse.
- The behavioral counseling intervention should follow the 5A’s approach adopted by the USPSTF: assess, advise, agree, assist, and arrange.
- Alcohol screening (G0442) is only covered one time in a 12-month period.
Critical Care Telehealth
- The provider may communicate with either the patient or the patient’s caregiver.
- A follow-up telehealth consultation is one requested by the attending physician and subsequent to an initial inpatient consultation whether provided in person or via telehealth.
- These consultations include monitoring the patient’s progress, as well as making recommendations and/or modifications to the patient’s management or instituting a new plan of care based on changes in the patient’s condition including no changes on the health issue for which the provider was consulted.
- Any counseling or coordination of care with other healthcare providers or agencies consistent with the nature of the problem and the patient’s needs is also included in the follow-up consultation service.
Other Telehealth Options
- A virtual check-in pays professionals for brief (5-10 min) communications that mitigate the need for an E/M
- These services are inherently telehealth and would be billed as a standard office service.
- Can be any real-time audio (telephone), or "2-way audio interactions that are enhanced with video or other kinds of data transmission."
- Established patients only.
- Any chronic patient who needs to be assessed as to whether an office visit is needed.
- Nurse or other staff member cannot provide this service. It must be a clinician who can bill E&M services.
- Should be initiated by the patient since a copay is required. Verbal consent to bill and documentation is required.
E-Visit – Physician (Provider Portal)
- An e-visit is when a beneficiary communicates with their doctors through online patient portals.
- Can be done synchronously and asynchronously and audio/video phone can be used (but not a traditional telephone)
- Must be patient initiated.The patient can initiate a virtual check-in, the practice can let the patient know about their options. If the patient calls back within 7 days, then the time from the virtual check-in can be added to the digital E/M code and only the digital E/M code is billed. Cost sharing applies to the E/M service; copays are waived for COVID-19 testing, but deductibles still apply.
- Use only once per 7-day period, Service time must be more than 5 minutes
- Clinical staff time is not calculated as part of cumulative time
- Do not report when billing remote monitoring, CCM, TCM, care plan oversight, and codes for supervision of patient in home, domiciliary or rest home etc. for the same communication[s]
- If the patient initiates a call to the physician office this would qualify for the remote check-in code (G2012), the time for the remote (virtual) check-in can be counted toward 99421-3 only if and when the patient calls back, so it is important to document the time.
Telephone Calls (With No Video Capabilities)
Telephone Calls (with no video capabilities)
- Telephone only (no video) are reimbursable by Medicare as well as many private payers during this public health emergency, and in California, all payers at the same rates and cost sharing as in-person services.
- No modifier is needed for these codes because they are not telehealth – they are audio only telephone.
- Use your normal Place of Service. For instance, POS=11 (private practice)
Payor Specific Policies
Annual Wellness Checks- Medicare
- Medicare has approved these services for payment as telehealth.
- G0438 ($189.87) - initial
- G0439 ($129.49) - subsequent
- Some payors have adjusted their prior authorization requirements during the pandemic, verify with your respective payors as to their specific policy.
Work Comp Telehealth
- Must inform patient
- Obtain verbal or written consent, document patient consent in medical record
- Adopted coverage for telephone visits at Medicare rates retroactively effective to March 1, 2020
- Use POS 11 (or location where provider would normally provide service)
- Reimbursement is at non-facility rates if POS 11 is retro effective to March 1, 2020
- Medicare list of allowable telehealth codes adopted
- No restriction to type of providers that can provide telehealth
- WC report and ML report are paid at same rate.
- QME evaluations are allowed via telehealth when an in-person physical exam is not necessary
Summary Of Services With Audio/Video Requirements
VP Revenue Cycle Operations
Medical Specialties Managers, Inc.