ED Coding and Reimbursement Alert

Hint: Keep an eye on CMS’ website to find out when adjusted rules subside.

Most ED staffers agree that CMS’ decision to broaden the telehealth rules during the COVID-19 pandemic has been beneficial to both patients and providers. But coders have faced a few obstacles when trying to interpret some of the telehealth regulations, and many readers have submitted questions to ED Coding Alert on this topic.

We’ve collected the three questions that our readers are most frequently asking about telehealth, along with answers straight from the sources.

Keep in mind: Information related to COVID-19 is changing rapidly. This information was accurate at the time of writing. Be sure to stay tuned to future issues of Emergency Department Coding Alert for more information.

Question 1: Which POS Should I Use — And How Long Will This Last?

In the past, telehealth was only payable by Medicare if patients were in a specific health setting during the visit, and only when certain technologies were used. So with the new changes that allow telehealth to take place in any setting and using a wider range of platforms, some emergency departments are wondering which place of service (POS) they should use on their claims, and how much longer they can bill this way.

In black and white: “When billing professional claims for non-traditional telehealth services with dates of services on or after March 1, 2020, and for the duration of the Public Health Emergency (PHE), bill with the Place of Service (POS) equal to what it would have been in the absence of a PHE, along with a modifier 95, indicating that the service rendered was actually performed via telehealth,” CMS says in its March 31 MLN Connects Special Edition newsletter. In addition, Part B payer NGS Medicare noted in an April 15 email blast, “At this time, there is no end date to the PHE.” Thus, you should stay on top of how long the PHE lasts and make sure you are aware of when CMS ends the special telehealth regulations.

The use of modifier 95 (Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system) tells the payer that you performed the service via telehealth, while using your POS (such as 23 for the ED) tells the insurer that the provider was based in the ED when the telehealth visit took place.

Don’t do this: Practices should avoid adding the POS for telehealth (02) to these claims during the PHE. Although that’s traditionally the right POS for telehealth, that’s not how things work during the pandemic under CMS’ relaxed rules. And some payers are reminding practices that you can never report more than one POS on your paper claims.

In black and white: NGS Medicare said in an April 15 email blast, “We have received a high volume of paper CMS-1500 claim forms for telehealth services with dates of service during the public health emergency (PHE) that we have to reject because they are improperly coded with two different place of service (POS) codes on one claim. The CMS-1500 paper claim form cannot contain more than one POS.”

Putting it all together: Suppose you see a patient who is concerned that their poison ivy rash is infected. The visit takes place via Skype, and the physician is in the ED, while the patient is in their home. The documentation describes an expanded problem focused history, an expanded problem focused exam and medical decision making (MDM) of moderate complexity. Based on the details of the visit, the ED physician advises the patient that the poison ivy appears normal and recommends some over-the-counter topical medications to alleviate discomfort and itching. For this visit, the physician will report 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components…) with modifier 95 appended. They will use POS 23 and the ICD-10 code L23.7 (Allergic contact dermatitis due to plants, except food).

Question 2: What If We Don’t Have Approved Telehealth Devices?

Several readers have asked ED Coding Alert how they can report telehealth visits if they don’t have the electronic devices that CMS previously approved for these services. Fortunately, CMS has updated the regulations temporarily, allowing you to use a much wider variety of devices for these visits during the PHE.

In black and white: “For the duration of the public health emergency … interactive telecommunications system means multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner,” CMS says in the interim final rule issued on March 31. “The HHS Office for Civil Rights (OCR) is exercising enforcement discretion and waiving penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the PHE for the COVID-19 pandemic.” However, CMS has said that public facing platforms such as Facebook Live are not permissible since they cannot maintain HIPAA privacy standards.

Bottom line: Although you are still bound to demonstrate a good faith effort to keep all patient information safe, you can venture outside of the previously approved telehealth device guidelines during the PHE.

Question 3: How Should We Report Phone-Based Visits?

Although many physicians are performing visits via telehealth (which requires two-way synchronous real-time communication via audio-visual technology), not all patients are equipped to speak to their physicians this way, and some are instead requesting phone visits, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania. Fortunately, during the PHE, CMS also adds audio phone calls as covered services.

In black and white: “A broad range of clinicians, including physicians, can now provide certain services by telephone to their patients (CPT^® codes 98966 -98968; 99441-99443),” CMS says in a March 30 fact sheet.

For telephone interactions, you should report:

• 99441 (Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian 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)
• 99442 (… 11-20 minutes of medical discussion)
• 99443 (… 21-30 minutes of medical discussion)

Don’t worry about “established” patient status. Several coders have contacted ED Coding Alert to express concern about the fact that these descriptors all use the words “established patient.” The concept of new and established patients is not applicable to the ED, causing many people to wonder how to designate an established patient phone call. Fortunately, CMS addressed that issue also, noting that it softened the “established patient” rules surrounding these codes.

In black and white: “We believe it is important during the PHE to extend these services to both new and established patients,” CMS says in the interim final rule issued on March 31. “While some of the code descriptors refer to ‘established patient,’ during the PHE we are exercising enforcement discretion on an interim basis to relax enforcement of this aspect of the code descriptors. Specifically, we will not conduct review to consider whether those services were furnished to established patients.”

Example: A patient calls the ED physician to discuss a recent asthma attack. The physician discusses ways the patient can cut back on their current levels of strenuous physical activity, since the attack appears to have been exercise induced. The total phone call time is 15 minutes.

How to code this: Code this as a telephone service using 99442, since the service meets the criteria for this code.