Pulmonology Coding Alert

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

Your practice has probably been ramping up its telehealth visits ever since CMS relaxed its telehealth regulations to facilitate healthcare during the COVID-19 pandemic. Although the agency has been prolific in releasing answers to the myriad questions that practices have on the topic, some pulmonologists are still confused about the ever-changing rules.

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 Pulmonology 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 pulmonology practices 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 11 for the office) tells the insurer that the pulmonologist was based in the office 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 (example 11-office, 02-telehealth). The CMS-1500 paper claim form cannot contain more than one POS.”

Putting it all together: Suppose you see an established COPD patient for a six-month evaluation of their condition. The visit takes place via Skype, and the pulmonologist is in the office, while the patient is in their home. The documentation describes an expanded problem focused history and medical decision making (MDM) of low complexity. Based on the details of the visit, the pulmonologist calls in a prescription for a rescue inhaler to the patient’s pharmacy and notes that the patient is having an acute exacerbation to their COPD. For this visit, the physician will report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components…) with modifier 95 appended. They will use POS 11 and the ICD-10 code J44.1 (Chronic obstructive pulmonary disease with (acute) exacerbation).

Question 2: How Can We Select E/M Levels Without Exams?

Several readers have asked Pulmonology Coding Alert how they can select an E/M code for telehealth services when they aren’t able to perform a patient examination. Some have inquired about whether time-based services can be performed via telehealth, while others are wondering how to code when they don’t have time noted in the documentation.

Fortunately, CMS has updated the code selection regulations temporarily, allowing you to use the upcoming 2021 coding guidelines for now.

In black and white: “On an interim basis, we are revising our policy to specify that the office/outpatient E/M level selection for these services when furnished via telehealth can be based on medical decision making (MDM) or time, with time defined as all of the time associated with the E/M on the day of the encounter; and to remove any requirements regarding documentation of history and/or physical exam in the medical record,” CMS says in the interim final rule issued on March 13. “This policy is similar to the policy that will apply to all office/outpatient E/Ms beginning in 2021 under policies finalized in the CY 2020 PFS final rule. It remains our expectation that practitioners will document E/M visits as necessary to ensure quality and continuity of care. To reduce the potential for confusion, we are maintaining the current definition of MDM.”

Critical: If you choose to code based on time, keep in mind that the times will be based on the time guidelines currently in CPT^® — not the time guidelines that will go into effect in January. For instance, a 15-minute established patient office visit would code as 99213 because that’s the timespan that CPT^® 2020 sets for that code.

Best practice: “You should always record your time in case you need to use it to level the care,” advises Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

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. 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)

Example: An established patient calls the pulmonologist to discuss a recent asthma exacerbation. The physician discusses ways the patient can cut back on their current levels of strenuous physical activity. 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 that the patient is established and has initiated the call, and that a physician or other qualified healthcare professional has provided the service.

Keep in mind: Before using these codes, you must make sure services has not originated “from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment” per the code descriptors. Also, per pre-PHE guidelines, the patient must be established and must have initiated the contact before using the phone codes. Since these services represent non-face-to-face services, rather than “telehealth,” and are not on the list of services constituting audio-visual telehealth, do not append modifier 95 to phone services.