Introduction to Telehealth Coding

Clinical Issues and Solutions/Documentation Guidance

Susanne Talebian, CUA, CPC-I, CPC

Urol Nurs. 2020;40(4):195-200.

Abstract and Introduction

Introduction

On March 24, 2020, the Centers for Medicare & Medicaid Services (CMS) stated the use of telehealth is vital to combat COVID-19. This was after the Secretary of the U.S. Department of Health and Human Services (DHHS), in response to COVID-19, declared a public health emergency on January 31, 2020, under section 319 of the Public Health Service Act (42 U.S.C. 247d). This was done in an overall effort to minimize the risk of exposure and community spread, and increase access to care. The CMS and DHHS have also encouraged commercial insurance carriers to make available and increase usage of telehealth services.

The Health Resources Services Administration (HRSA) defines telehealth as the use of electronic information and telecommunications technologies to support this: long-distance clinical health care, patient and professional health-related education, health administration, and public health. Telehealth refers to a broader scope of remote health care services than telemedicine. Telehealth can refer to remote non-clinical services, such as provider training, administrative meetings, and continuing medical education, in addition to clinical services, while telemedicine refers specifically to remote clinical services.

One primary action that must be taken is to check with your malpractice insurance carrier to ensure you are covered to provide telehealth services. There is no federal legislation regarding coverage for telehealth services. Licensure is not uniform between states; however, most states have passed laws, and several states have telemedicine licensure bills pending. There are restrictions related to providers doing telehealth with patients in states other than where the provider is located, and cross-border billing does not apply to all licenses. The public health emergency of COVID-19 has created an exception to cross-border care and billing.

Telehealth services requirements must meet medical necessity, be completely documented in the patient's medical record chart, informed consent must be obtained from the patient, and interactive real-time audio/video communications must be conducted with the patient or caregiver. Types of telecommunications are defined by the DHHS and Office of Civil Rights (OCR) and include audio, landline, and wireless communications; text messaging; Internet; video communications; videoconferencing; and store-and-forward imaging. Commercial carriers follow state rules, and currently, 39 states and the District of Columbia have laws relating to telehealth/telemedicine services. Several states have parity laws that state payors will pay the same for telehealth services as in-person rates. The 11 states without parity laws at the time of this article are Alabama, Arizona, Idaho, North Carolina, Ohio, Pennsylvania, South Carolina, Utah, West Virginia, Wisconsin, and Wyoming. This varies by state and may also vary by insurance plan type (health maintenance organization [HMO], preferred provider organization [PPO], point-of-service [POS]), local plans, and exchange plans.

Office of Civil Rights Notification of Enforcement Discretion applies to all HIPAA health care providers, rendering telehealth services under good faith provisions of telehealth during COVID-19 to all telehealth patients until the end of the public health emergency (PHE). If a provider is using good faith, they are using non-public facing communications, and potential HIPAA breaches will not be brought against them. Good faith communications include Apple Facetime, Google Hangouts video, Facebook Messenger video chat, WhatsApp video chat, Zoom, and Skype. However, public-facing communications are considered bad faith and not acceptable. Bad faith communications include TikTok, Twitch, Facebook live, and any public chat room. Providers who can perform these services in a good faith communication portal include physicians, nurse practitioners, physician assistants, nurse midwives, clinical nurse specialists (CNAs), clinical psychologists, licensed clinical social workers, registered dietitians, and nutrition professionals. Providers must practice within their scope of practice and be consistent with Medicare benefit rules and according to Current Procedural Terminology (CPT) codes, which will specify as to type of provider. Unfortunately, physical therapists (PTs), occupational therapists (OTs), and speech language pathologists (SLPs) were not included in the initial expansion, although some facilities may be offering video visits to cash pay patients or under "incident to" rules.

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Next Section

Abstract and Introduction
Telehealth Services and Locations That can be Rendered, and Eligible Patients
Other Telehealth Services That can be Rendered
Patient Home-based Services
Coding and SARS-COVID-19
Conclusions
References

Table 1. Billing Codes Based on Time in Minutes
Code	CPT	CMS
99201	10	17
99202	20	22
99203	30	29
99204	45	45
99205	60	67
99212	10	16
99213	15	23
99214	25	40
99215	40	55

Table 2. Non-Face-to-Face Evaluation and Management Services
Visit Type	Description	Codes
eVisits – Online Digital visits	Patients must generate the initial inquiry, and communications can occur over a 7-day period via a patient portal, and can be rendered by practitioners who may independently bill Medicare for evaluation and management visits.	Cumulative, time-based codes for a 7-day period, cumulative time during the 7 days.	99421: 5–10 minutes
			99422: 11–20 minutes
			99423: 21 minutes or more
eVisits – Online Digital visits for Non-MD	Clinicians who may not independently bill for evaluation and management visits (for example – physical therapists, occupational therapists, speech language pathologists, clinical psychologists, dieticians) can provide these e-visits.	Online digital evaluation and management service for an established patient for up to 7 days, cumulative time during the 7 days.	G2061: 5–10 minutes
			G2062: 11–20 minutes
			G2063: 21 minutes or more
Telephone calls – Audio only rendered by physician or other qualified health care professional	Telephone evaluation and management service provided by a provider to an established patient, parent, or guardian point-of-service plan normally rendered in office but may also be rendered from the provider's home (provider's home address does not need to be listed claim forms).	Not originating from a related evaluation and management (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.	99441: 5–10 minutes of medical discussion
			99442: 11–20 minutes
			99443: 21 or more minutes
Telephone calls – Audio only rendered by non-physician non-qualified health care professional	Telephone assessment and management service provided by a qualified non-physician health care professional to an established patient, parent, or guardian (for example – physical therapists, occupational therapists, speech language pathologists, clinical psychologists, dieticians).	Not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment.	98966: 5–10 minutes of medical discussion
			98967: 11–20 minutes
			98968: 21 or more minutes
Interprofessional Telephone/Internet Services	Interprofessional telephone/Internet assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional. Note: This can only be billed by the consulting physician.	Billed on time spent. Provider can be a medical doctor, nurse practitioner, or physician assistant. Do not bill more than once in 14 days.	99446: 5–10 minutes of medical consultative discussion and review
			99447: 11–20 minutes
			99448: 21–30 minutes
			99449: 31 minutes or more
	Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician can be rendered for new or established patients. Note: This can only be billed by the consulting physician.	Includes a written report to the patient's treating/requesting physician or other qualified health care professional.	99451: 5 or more minutes of medical consultative time
	Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or qualified health care professional, 30 minutes of medical consultative time. Note: This can be billed by the requesting physician or qualified health care professional.	Must meet the greater than 50% rule on time.	99452: 30 minutes of medical consultative time.

Table 3. Confirmed COVID-19 Case
Confirmed COVID-19 Case
U07.1	COVID-19, CONFIRMED cases by local or state testing or CDC.
U07.1	COVID-19 asymptomatic individuals who test positive for COVID-19. This is a new code that will be in the 2020 ICD10CM update to release on October 1, 2020.
For Screening of Patients
Z11.59	Encounter for screening for other viral diseases. For asymptomatic individuals who are being screened due to a possible or actual exposure to COVID-19 and have no known exposure to the virus, and test results are either unknown or negative.
Z03.818	Encounter for observation for suspected exposure to other biological agents (COVID-19) ruled out.
Z20.828	For cases where there is an actual exposure to someone who is confirmed or suspected (not ruled out) COVID-19, and the exposed individual either tests negative or the test results are unknown.
For Manifestations and COVID-19
U07.1	COVID-19 Sequenced first, followed by the appropriate codes for associated manifestations Examples: J12.89 Other viral pneumonia. J20.8 Acute bronchitis due to other specified organisms
	Obstetrics patients O98.5 Other viral diseases complicating pregnancy, childbirth, and the puerperium (U07.1 would follow when coding)

Table 4. Remote Physiologic Monitoring Services
99453	Remote monitoring of physiologic parameter(s), initial; set-up and patient education on use of equipment.	Device must be used greater than 16 days to bill this code. Bill once per episode of care. Defined as from initiation of the Remote Physiologic Monitoring program until the patient reaches their specific goals.
99454	Device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.	Report when recordings/programmed alerts greater than 16 days to bill this code. Bill every 30-day period. Device must meet FDA requirements of a medical device.
99457	Remote Physiologic Monitoring Treatment Management Services, initial 20 minutes or more professional time in a calendar month requiring live, interactive communication with the patient/caregiver during the month.	Must meet the full 20 minutes during a calendar month to bill this code.
+99458	Remote Physiologic Monitoring Treatment Management Services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month, subsequent 20 minutes.	Must meet the full additional 20 minutes to bill this add-on code. You cannot bill a fraction of the time. Maximum of two units per month.

Notes:
Remote Physiologic Monitoring
• Intended for the use in the diagnosis of disease or other conditions, treatments, or prevention of disease
• RPM is NOT considered general telehealth and therefore is not subject to those same restrictions under Medicare.
• Nor is it limited by geography to rural or medically underserved areas, nor is there any "originating site" restriction.
• RPM services can be provided anywhere the patient is located, including at the patient's home.
Requirements
• Advanced beneficiary consent.
• Ordered by QHCP.
• Face-to-Face visit with QHCP in past 12 months .
• Patient has received, from my practice, a medical device capable of wirelessly transmitting patient data and/or alerts daily to our practice.

Box 1. Documentation Example: Telehealth Services
This service is being rendered via telecommunications. The patient is aware of this and accepts any possible HIPAA risks and agrees to proceed. The encounter was started at XX AM/PM and ended at XX AM/PM Total of ___ minutes The patient is located at ________________ The provider is located at ________________

Box 2. Documentation Example: Patient Home-Based Services
Date of Encounter: __________________________________ Patient's Name: _____________________________________ Appointment with provider: ___________________________ Chief complaint: Reason for the visit in the patient's owns words______________________________________________ We discussed treatment options including doing nothing, prescribed medications, invasive procedures, and commitment to self-care. Diagnosis and treatment plan are as follows: ___________ ____________________________________________________ Diagnosis:__________________________________________ Specific patient goals are: ____________________________ ____________________________________________________ Defined, set, and documented in the patient record. The patient has freely chosen and is willing to proceed with a remote physiological monitoring program. We will proceed with patient education and initial setup of the device. We have provided a medical device with daily recordings or alerts. The patient understands that compliance and adherence to this program is necessary to reach the goals and improve their health. Provider name, signature, date:_______________________ ____________________________________________________

Box 3. Documentation Example: Interprofessional Telephone/Internet Services
This Interprofessional service is being rendered via telecommunications. Requesting QHCP Consulting Physician The encounter was started at XX AM/PM and ended at XX AM/PM Total of ______ minutes Continue with your discussion… The consulting physician provided and documented the verbal and sent the written report to the requesting physician.