General Surgery Coding Alert

Add this clip-and-save chart to your telehealth toolbox.

After adjusting to telehealth changes with the end of the COVID-19 public health emergency (PHE) earlier this year, providers are coming to grips with the fact that this type of patient encounter isn’t going anywhere.

That means your surgery practice should study the possibilities and decide how to make the most of telehealth options in 2024.

Background: The Centers for Medicare & Medicaid Services (CMS) plans to implement the Consolidated Appropriations Act (CAA), 2023, telehealth services provisions through the end of 2024, according to the calendar year (CY) 2024 Medicare Physician Fee Schedule (MPFS) final rule. That includes paying the non-facility MPFS rate for at-home telehealth services, lifting geographic restrictions, and allowing Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to provide telehealth services.

Opportunity: Telehealth provides patient convenience and accessibility that could dramatically improve care quality and compliance when patients are able to schedule appointments without taking time off from work or taking kids out of school.

Code Telehealth With Confidence

You need to consider the following factors as you strive to master compliance and coding for these services:

• Know the entire range of code choices.
• Pay attention to time and how it’s counted.
• Stay on top of rules and guidelines as they change.
• Know which services do and don’t require a physician.
• See how proximity to other evaluation and management (E/M) services impacts telehealth.

Tool: The clip-and-save chart at the end of this article provides a handy list of telehealth codes in a format that considers all the preceding factors.

Look For a Good Vendor

Your surgery practice may already be using a telemedicine platform, but the market is maturing as more players enter the field. That means you might need to reassess what’s best for your office.

“We’ve got a lot of different types of technology [for telemedicine]. It’s really a noisy space, and it’s making it very difficult for buyers to make a good, solid decision on what’s the right technology pathway to go,” says Lisa Lavin, founder and CEO, Ōmcare Inc. in Bloomington, Minnesota.

If you’re experiencing this kind of confusion, consider the following factors in your decision making:

• User-friendly Platform: Healthcare providers and their patients should all be able to use the system. If it’s too complicated, no one will want to use it.
• Compliance: Your vendor should prioritize relevant healthcare regulations, such as HIPAA, to ensure patient information is secure.
• Compatibility: You also want to look for a system that can easily integrate with your existing electronic health record (EHR) system. You don’t want a new system to trigger EHR errors. Also, you’ll want to be sure that the internet speed is a good match for the services you’re looking into. Some locations don’t have reliable internet, so offering patients accessibility on multiple devices, such as a mobile app or text message can be good choices.
• Ongoing Support: Be sure to ask about the company’s technical support. Good vendors will provide ongoing support to make sure your system is always up and running.

Establish a Solid Training Program

Even with an easy-to-use technology, you can expect a learning curve. Users will need to learn the technology, and also how to integrate new processes into everyday practice.

Do this: Involve surgeons, schedulers, coders, and any other relevant staff in the training. Here are some of the items you should cover:

• Clinical Training: Clinicians need to know how to conduct and thoroughly document a virtual examination.
• Communication Training: Staff need to effectively communicate with patients and their families through a virtual platform. This includes both verbal and non-verbal communication skills.
• Legal and Regulatory Training: Staff need a solid understanding of all aspects of telehealth, including understanding the relevant telehealth laws and regulations in their state, and how to maintain compliance with HIPAA and other privacy laws.
• Emergency Procedures Training: You must establish a protocol and make sure all staff members know how to handle emergencies during a telehealth visit, including when and how to direct a patient to seek immediate in-person care.
• Patient Education: Staff also need full understanding of how to educate patients and their families on how to use the telehealth platform, what to expect during a telehealth visit, and how to prepare for a telehealth visit. Educating patients also includes promoting how telehealth can be an advantage to them.

Note: Don’t underestimate the role practice schedulers play. This is an area that some practice managers overlook. “Understanding which visits could be done with a simple telehealth visit and which ones require an in-person visit might be the most important success factor,” says Chip Hart, director of Pediatric Solutions at Physician’s Computer Company in Winooski, Vermont.