Otolaryngology Coding Alert

See what sets telehealth apart from the rest of the virtual services.

In this unprecedented time, the healthcare system has been forced to adapt to treating patients using the most efficient and practical means possible. The COVID-19 epidemic has resulted in an essential need to treat patients outside of the general conventions of what typically qualifies as an office visit or other face-to-face encounter.

That’s why the Centers for Medicare & Medicaid Services (CMS) issued a series of press releases (March 17 and March 30) in addition to an interim final rule published in the Federal Register on April 6. (https://www.cms.gov/files/document/covid-final-ifc.pdf). “These changes allow seniors to communicate with their doctors without having to travel to a healthcare facility so that they can limit risk of exposure and spread of this virus,” explains CMS Administrator Seema Verma. “Clinicians on the frontlines will now have greater flexibility to safely treat our beneficiaries,” Verma adds.

The press briefings and subsequent final rule outline a number of new policies surrounding extensions in telehealth billing during the COVID-19 virus public health emergency (PHE). The most up-to-date list of coronavirus waivers and flexibilities can be found at: https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emergencies/coronavirus-waivers.

Under normal circumstances, practitioners and patients would have to navigate through a series of requirements in order to meet the appropriate criteria for virtual telehealth services. But until further notice, many of these guidelines are completely dissolved. Providers are now capable of performing evaluation and management (E/M) office services, among a plethora of other services, using a virtual form of communication.

In this first article of a two-part telehealth suite, we’re going to focus on the coding guidelines surrounding Medicare telehealth services. Read on to get answers to your top questions.

Distinguish Medicare Telehealth From 3 Other Services

Telehealth, telemedicine, and patient portal interactions between practitioner and patient via a virtual means of communication can be divided into four forms of service, as defined by Medicare Part B:

• Medicare telehealth visits.
• Virtual check-ins.
• E-visits.
• Remote monitoring.

Without a proper distinction, it’s easy to confuse or overlap the services provided within each respective option. First, you’ll want to understand what’s needed to code a virtual service as a Medicare Part B telehealth visit. These visits are designated for patient encounters that would typically occur in-person. This would include an office visit, hospital visit, home visit for a homebound patient, or another form of face-to-face interaction with the provider. Patients may communicate with a practitioner from a healthcare facility or, most typically, from within their own home, as a result of the COVID-19 exceptions.

However, in order for a visit to qualify as a Medicare telehealth visit, the patient must use “an interactive audio and video telecommunications system that permits real-time communication between the distant site and the patient at home,” according to CMS in the March 17 press release (https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet).

Meeting the requirements for a telehealth service can most easily be achieved using a smartphone and an app. There are also HIPAA-compliant apps that are integral to many electronic health record (EHR) systems, in addition to standalone apps, such as Doxy.me and Chiron. Furthermore, the COVID-19 expansions of services and HIPAA waivers now allow practices to use more common interactive applications such as Facetime and Skype. These services will be reimbursed at the same rate as an in-person visit.

Note: Semantics is important in distinguishing forms of communication between patient and provider. The term “telemedicine,” as opposed to “telehealth,” refers to communication using audio-only methodology.

With respect to otolaryngology, the following practitioners are eligible to perform and receive reimbursement for Medicare telehealth visits:

• Physicians,
• Nurse practitioners (NPs), and
• Physician assistants (PAs).

Services that require direct supervision by the physician may also be provided virtually, using real-time audio/video technology.

Note: Initially, when the COVID-19 exceptions were first released, CMS indicated that the patient must have an established relationship with the provider for a telehealth encounter. But the March 30 press release and subsequent interim final rule indicate that practitioners may provide telehealth services to new patients, in addition to established patients.

Elaborate on Medicare Coding Guidance

A typical Medicare telehealth visit, which simulates an E/M office/outpatient encounter, should be reported using the E/M office/outpatient visit code range 99201-99215. However, the March 30 press release outlines more than 80 services that will qualify for Medicare telehealth billing. Some of these services include:

• Emergency department;
• Initial nursing facility and discharge;
• Inpatient neonatal and pediatric critical care;
• Critical care;
• Domiciliary, rest home, or custodial care; and
• Home visits.

You can download the entire code list of covered telehealth services from CMS at: www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.

General rule: You’ll report the respective E/M code for the location that the telehealth service would have taken place had there not been a PHE. However, with respect to otolaryngology, you won’t often venture beyond code range 99201-99215 for your telehealth reporting. This includes patients that meet the CMS definition for homebound. Do not code these as home visits.

For a breakdown of other essential coding guidance on Medicare telehealth visits (modifiers and place of service [POS] codes), read “Shift Your Focus to Virtual Check-Ins, E-Visits, and More” in this issue.

E/M coding note: On page 141 of the interim final rule, CMS explains that your E/M level selection may be based on medical decision making (MDM) or time. This is similar to the upcoming changes to E/M reporting for the 2021 calendar year with two distinct differences. First, MDM coding will be based on the current definition of MDM and the existing MDM tables. Similarly, for time-based coding you should refer to the typical times associated with the office/outpatient E/M codes.

Consider Expert Billing Guidance

With respect to telehealth services billing, CMS outlines that the Office of Inspector General (OIG) will provide “flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.” Marie Popkin, CPC, CMCS, BSM, ProFee Auditor at HCCS HIM Services in Fort Myers, Florida, explains what exactly that does, and does not, mean for physician practices: “In order to fully understand how this translates to your practice, you need to first check payer policy. One common assumption is that you have to submit an appeal when the copay is not covered by the payer following reimbursement. However, that’s only true if your local carrier is picking up the copay,” explains Popkin.

Note: CMS explains that you should append modifier CS (Cost-sharing for specified covid-19 testing-related services that result in an order for or administration of a covid-19 test) “on applicable claim lines to identify the service as subject to the cost-sharing wavier for COVID-19 testing-related services. For a complete breakdown of what E/M claims are eligible, read about the Families First Coronavirus Response Act at: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-04-07-mlnc-se

Disclaimer: 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 Otolaryngology Coding Alert for more information. You can also refer to payer websites, CMS (cms.gov), CDC (cdc.gov), and AAPC’s blog (www.aapc.com/blog) for the most up-to-date information.