Pediatric Coding Alert

These 6 big takeaways will help you move forward with your virtual services.

The COVID-19 public health emergency (PHE) has had a huge impact on telehealth/ telemedicine, with rules and regulations seemingly changing on a weekly basis. But with the end of the pandemic now on the horizon, many are asking what the telehealth landscape will look like after the PHE is over.

In her HEALTHCON 2021 presentation, “Telemedicine: Achieving Documentation and Coding Success,” Stephanie Sjogren, CPC, CPMA, CCS, CPC-I, CDEO, HCAFA, director of medical coding and provider reimbursement at ConnectiCare in Bristol, Connecticut, surveyed the current telehealth territory. Here are the main takeaways from that presentation, including her insights into telehealth best practices and her predictions for telehealth services once the PHE ends.

Checking Medicare and Private Payer Policies

First, you’ll need to look at the fine print. “Some payer policies state they cover telehealth, but before you start up your telehealth program, you need to do your research,” Sjogren warned. That means finding out if:

• Your payer will let you render telehealth services and reimburse you;
• Your payer has turned telehealth over to a vendor (though you can ask for an exception if you can show your program will have value and be cost efficient);
• Your payer’s requirements for HIPAA compliance; and
• Your payer’s other telehealth policies, including what services will be covered; what providers will be eligible to provide telehealth services; how you should document telehealth services, including what modifiers and place of service (POS) codes you should use; whether there will be geographic and originating site restrictions; and whether you need out-of-state licensure.

Telehealth Documentation Best Practices

Simply put, “telehealth documentation should not be any different than any other in-person visit,” according to Sjogren, though you should be sure to note the modality (video and audio, audio only, or asynchronous message/data) in order to justify the CPT^® code billed. Additionally, you will need to show that the patient consented to telehealth, which means keeping an annual consent form on file and referring to it in the note and noting that your pediatrician was able to verify that the person being seen/ spoken to during the virtual encounter was the patient or the patient’s parent/caregiver.

“This means the record should contain statements like: ‘This visit was conducted using asynchronous audio/video with Mom and patient present. Mother understands that the exam will be limited and may require the patient to present in person after the telemedicine visit. Mother voiced understanding and gave consent for this type of visit. History presented by mother and patient,’” says Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

Reviewing/Auditing Documentation

In addition to making sure all the above have been documented, a review of the record needs to verify that the telehealth provider is qualified to provide the service. Also, for evaluation and management (E/M) services furnished virtually, you will need to make sure the code you select matches the level of medical decision making (MDM) or time documented, though some private payers “may still require a history and an examination to be at the required level for the CPT^® code selected,” Sjogren adds.

Consequently, “if you are billing using the office visit codes 99212-99215 [Office or other outpatient visit for the evaluation and management of a new/established patient …], you should have an appropriate history and exam pertinent to the chief complaint and presenting problems, but the level of care will be based on MDM or time based on CPT^® guidelines,” advises Holle.

Telehealth During the PHE

Currently, the Department of Health and Human Services (HHS) has relaxed many telehealth rules and regulations to allow for safe and flexible healthcare delivery during the PHE. They include such waivers as expanding the number of services allowed, allowing the patient’s home to be an originating site, and “allowing telehealth to be conducted on video-enabled phones using Facetime and Zoom, even when these are not considered to be ‘secure’ but more available for parents/patients,” Holle notes.

The current rules also require you to bill for telehealth using the place of service (POS) code you would have used if the service had occurred face-to-face, such as POS 11 (Office), rather than POS 02 (Telehealth). And they also require modifier 95 (Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system) to be appended on real-time services that are on the Centers for Medicare & Medicaid Services’ (CMS’) current telehealth list (found at www.cms. gov/Medicare/Medicare-General-Information/Telehealth/ Telehealth-Codes).