Telehealth Examination Guidelines

lori.l.thompson@state.or.us

New
Local Chapter Officer
Messages
6
Location
Salem, OR
Best answers
0
Hoping that I can get some guidance here.

During two separate audits of telehealth visits performed during the pandemic, our auditors identified that providers are noting “no exam performed” in the charts. The examination is a key component when selecting the level of Evaluation and Management (E/M) code. Upon further review of telehealth guidelines issued during the pandemic, there is a lack of guidance on how to code these visits if an exam is listed as not being performed. These visits are being coded as 99201-99205 and 99212-99215 by the providers.

During the Coronavirus pandemic providers were encouraged to provide telehealth services whenever possible. These services should reasonably approximate an in-person visit. Coverage of telehealth services requires the same level of documentation, medical necessity, and coverage determinations as in-person visits. If the requirements are met, reimbursements are the same as reimbursement for in-person services.

Can anyone steer me in the right direction for guidance for documentation for the E&M portion of a telehealth visit?
 

csperoni

True Blue
Messages
1,824
Location
Selden
Best answers
3
Even for telehealth, there may be some exam component. General. Psych. Skin.
We didn't see any new patients via telehealth, but we're gyn oncology. For our established patients, in 2020 we were billing on 2 of 3 for hx/exam/MDM or time. I recall seeing guidance from CMS that you could use MDM only for coding telehealth even in 2020. My quick google search didn't find an official CMS reference, but rather other references mentioning it, like this MGMA document:
Reporting of E/M Visit Level:
For the duration of the public health emergency, CMS will permit reporting of telehealth E/M office or other outpatient visits based on either (1) time, which is defined as all of the time associated with the E/M on the day of the encounter; or (2) Medical Decision Making (MDM). CMS is not requiring history or exam to be used in selecting an E/M service via telehealth.
This temporary policy is similar to the policy that will apply to all office/outpatient E/M services beginning in 2021 under policies finalized in the CY 2020 PFS final rule.
If it is a private payor, they may have had different guidelines than CMS.

If the carrier is Medicare, Medicaid or anyone following CMS rules, exam was not required for telehealth even in 2020.
If the carrier required 2020 E/M coding for telehealth without a policy change, then visits may have been incorrectly coded.
 

TThivierge

Expert
Messages
288
Location
Lithonia, GA
Best answers
0
Hi Lori
At my facility we use telehealth all the time. Here is our documentation guidelines, the provider must start note off writing/stating doing Video Conference(Zoom) or telehealth phone call visit. They must put in top of note used 2 verification methods to ensure correct patient speaking too. We use name, address, DOB. Also a small statement from doc ensuring patient gave permission for telehealth . Add all that in the provider documentation of telehealth treatment. Or the nurses documents this before she lets doc do the treatment over the phone. After 2 patient verifications done then add telehealth minutes at end of documentation which coincides with the CPT selected

The provider does list all the same data on MDM, SOAP, nature of complaint or follow up listing the medical problem. If licensed MD,DO,NP or PA use the CPT 99441-99443, no modifier 95. If a peer specialist, sleep study tech, therapist tech, or RN nurse doing the phone call /telehealth use CPT 98966 series .All providers or techs must talk to patient at least 5-10 minutes . They should have discussed the patient ongoing dx code or current assessment and PMH list. Medication reviews are a big one with our MD DO NP PA so use dx Z51.81. They must put this in the note discuss patient medications or reviewed medications at the end of treatment note. Plus MAR form on template helps. Now if the MD or psychiatrist or LPC or LCSW talks to the patient about ongoing chronic conditions then add another paragraph on discussing MH problem we bill both 90832 and 99214 adding modifier 95 on each of these CPT. (Add modifier 95 if the VVC or telehealth is used in treatment). The provider let s say spent 10 minutes discussing chronic medical issues(99213) and then 20 minutes on behavioral psych health problem.(90832). I hope this helps you. Oh yes if telehealth visit runs long like over 60 minutes use the prolong services CPT but provider must tell the time use words "prolonged visit" in notation. There is list of Prolonged CPT codes to use with telehealth in the CPT manual year 2021.
I hope this data helps you
Lady T:)
 

csperoni

True Blue
Messages
1,824
Location
Selden
Best answers
3
Hoping that I can get some guidance here.

During two separate audits of telehealth visits performed during the pandemic, our auditors identified that providers are noting “no exam performed” in the charts. The examination is a key component when selecting the level of Evaluation and Management (E/M) code. Upon further review of telehealth guidelines issued during the pandemic, there is a lack of guidance on how to code these visits if an exam is listed as not being performed. These visits are being coded as 99201-99205 and 99212-99215 by the providers.

During the Coronavirus pandemic providers were encouraged to provide telehealth services whenever possible. These services should reasonably approximate an in-person visit. Coverage of telehealth services requires the same level of documentation, medical necessity, and coverage determinations as in-person visits. If the requirements are met, reimbursements are the same as reimbursement for in-person services.

Can anyone steer me in the right direction for guidance for documentation for the E&M portion of a telehealth visit?
I came across the official CMS guidance that even for 2020, you could code outpatient E/M telehealth on MDM only.
CMS issued guidance that even in 2020, telehealth could be coded on MDM only or time.
From https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf currently on page 96 (my emphasis added):
"In the May 8, 2020 COVID-19 IFC, for the duration of the PHE, we also expanded the primary care exception to include the following services: Telephone E/M services (CPT codes 99441–99443), Transitional Care Management (CPT codes 99495-99496), and Communication Technology-Based Services (CPT codes 99421–99423 and 99452, and HCPCS codes G2010 and G2012). For office/outpatient E/M services furnished via telehealth, the E/M level selection 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. We also removed any requirements regarding documentation of history and/or physical exam in the medical record.
New: 6/19/20"
 

ruthan

Networker
Messages
61
Location
Dimondale, MI
Best answers
0
so am I understanding correctly if a telehealth visit (thru computer/phone visual) we use the E/M levels. But if it is strictly over the telephone then we are to use the 99441-99443 codes?
 

csperoni

True Blue
Messages
1,824
Location
Selden
Best answers
3
Yes, that is the CMS advice. Telehealth code as E/M 99202-99215 if audio/video. Telephone only is 99441-99443.
Caveat: There are some commercial payors that advised to use E/M even if telephone only. While that is not the correct coding per CMS or AMA, if you have a written policy from the carrier, you may follow that written policy. Each carrier also has their own policy whether they want -95 or -GT on telehealth and what POS to use. We are using CMS guidelines for all carriers unless they have issued a policy otherwise.
 
Messages
6
Best answers
0
Yes, that is the CMS advice. Telehealth code as E/M 99202-99215 if audio/video. Telephone only is 99441-99443.
Caveat: There are some commercial payors that advised to use E/M even if telephone only. While that is not the correct coding per CMS or AMA, if you have a written policy from the carrier, you may follow that written policy. Each carrier also has their own policy whether they want -95 or -GT on telehealth and what POS to use. We are using CMS guidelines for all carriers unless they have issued a policy otherwise.
I have a situation where the provider is doing the visit as both phone and in-person. The patient presents with covid symptoms and is in the facility parking lot - the provider begins with a phone visit, but also goes out and takes necessary vitals such as pulse ox, temperature, listens to the lungs, and does a covid test. They also give health advise in person. Would this be billed as whatever the majority of the encounter time was (either phone or in person)? Or would it depend on where the medical decision making happened?
 
Messages
356
Best answers
0
I have a situation where the provider is doing the visit as both phone and in-person. The patient presents with covid symptoms and is in the facility parking lot - the provider begins with a phone visit, but also goes out and takes necessary vitals such as pulse ox, temperature, listens to the lungs, and does a covid test. They also give health advise in person. Would this be billed as whatever the majority of the encounter time was (either phone or in person)? Or would it depend on where the medical decision making happened?
Medicare wants those encounters reported as a face-to-face visit. From a COVID-19 FAQ

Services should only be reported as telehealth services when the individual physician or practitioner furnishing the service is not at the same location as the beneficiary. If the physician or practitioner furnished the service from a place other than where the beneficiary is located (a “distant site”), they should report those services as telehealth services. If the beneficiary and the physician or practitioner furnishing the service are in the same institutional setting but are utilizing telecommunications technology to furnish the service due to exposure risks, the practitioner would not need to report this service as telehealth and should instead report whatever code described the in-person service furnished.
 

KoBee

Expert
Messages
291
Best answers
0
Hello, can i get some advice on the telephone only 99441-43. So much to established but i just want to make sure it's correct what im understanding. I believe the descriptions of CPT codes 99441-43 is what is throwing me off a little. If patient consents to do a telehealth visit, unable to connect on video so the visit turns into audio only, still establishes HPI, self exam, MDM. I had an understanding we are to code 99202-99215. Is that correct or not? Thank you, any feedback is greatly appreciated it.
 

carlystur

Guru
Messages
223
Best answers
1
I believe that depends on the payer for which set of codes they'll accept for audio-only. From what I understand, correct coding for audio-only encounters are the phone codes 99441-43.
 

TThivierge

Expert
Messages
288
Location
Lithonia, GA
Best answers
0
Hi KoBee
If your provider decides to use Eva/Mgnt 99202 - 99215 add the modifier 95 to represent telehealth (be it Zoom video or phone). Also in documentation doctor needs to verify correct patient, pt. address and demographic info since it is a phone conversation. in documentation. Provider needs to tell amount of minutes (minimum is 5 minutes) he spoke with patient on the phone too in the notation. Then use MDM, SOAP, ROS, tell nature of complaint, and medication checked dx Z51.81 or prescriptions given dx Z76.00 or lab reviewed dx Z71.2 in notation too if appropriate. This can be used for any MD, NP and PA status clinician. If nurses phone patient use CPT 98966 series without modifier 95. Ensure the provider s list dx/ assessment on med record then sign or attest when finished.
I hope I helped you with this data:)
Lady T
 

csperoni

True Blue
Messages
1,824
Location
Selden
Best answers
3
Hello, can i get some advice on the telephone only 99441-43. So much to established but i just want to make sure it's correct what im understanding. I believe the descriptions of CPT codes 99441-43 is what is throwing me off a little. If patient consents to do a telehealth visit, unable to connect on video so the visit turns into audio only, still establishes HPI, self exam, MDM. I had an understanding we are to code 99202-99215. Is that correct or not? Thank you, any feedback is greatly appreciated it.
This can be dependent on the carrier. CMS has specifically issued a guidance that audio only is 99441-99443. Almost all of my contracts follow the Medicare guidelines and I am not aware of any carrier advising to use 99202-99215 for audio only, but I do know that some carriers have done so.
Here are the Medicare FAQ https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf. It is specifically addressed in the telehealth section, question 26:
Question: If the video connection is disconnected during an audio-video Medicare telehealth visit due to technological issues, can the visit still be billed as Medicare telehealth?
Answer: Practitioners should report the code that best describes the service. If the service was furnished primarily through an audio-only connection, practitioners should consider whether the telephone evaluation and management or assessment and management codes best describe the service, or whether the service is best described by one of the behavioral health and education codes for which we have waived the video requirement during the PHE for the COVID-19 pandemic. If the service was furnished primarily using audio-video technology, then the practitioner should bill the appropriate code from the Medicare telehealth list that describes the service. Note that CPT codes 99441–99443,
which describe audio-only telephone E/Mphone visits with practitioners who can independently bill for E/M services, have been added to the Medicare telehealth list for the purposes of the PHE for the COVID-19 pandemic, and payment rates for these codes are set to be the same as the analogous in-person E/M visits.
New: 5/27/2020
 
Top