From 3M Health Information Systems
Telemedicine: Virtual health care during COVID-19
Back in February, I wrote a blog about telemedicine, precisely about the benefits and some coding specifics. At that time, I had no idea COVID-19 would become so prevalent and how important telemedicine services would become. As people enter quarantine because of exposure, COVID-19 diagnosis, or are required to stay put, telehealth services have become vital to safe patient treatment. The first question that comes to my mind is, “How do I navigate through daily coding and policy changes?”
Medicare has been covering telehealth services under certain circumstances for patients since 2018, but the onset of COVID-19 means expanded coverage for both Medicare and many commercial payers are following CMS’ lead. The current administration announced expanded coverage for telehealth services for Medicare members and relaxed HIPAA enforcement to combat the current COVID-19 pandemic. Since this time, there have been numerous updates announced by Medicare such as additional codes that will temporarily be covered for telemedicine visit. It was also announced Medicare would reimburse doctors and hospitals for “a broad range of telehealth services on a temporary basis, effective March 6, 2020.” According to CMS Administrator Seema Verma, “These services can also be provided in a variety of settings, including nursing homes, hospital outpatient departments, and more.” Administrator Verma went on to indicate, “Office for Civil Rights will allow providers to deliver telehealth services for any diagnostic or treatment purpose, even if it’s unrelated to COVID-19, so long as they do so ‘in good faith.'” Additionally, HHS will temporarily allow doctors to provide telehealth services with their personal phones and use enforcement discretion related to copays, so cost is not a barrier to patient care. The Department of Health and Human Services advised that Public-facing applications such as Facebook Live, Twitch, and TikTok should not be used for telehealth services as they put patient privacy at risk.
Resources for telehealth coverage for Medicare patients can be found on the CMS website, and provider billing office staff should be reviewing payer websites for updated telehealth policies for patients with commercial insurance. We encourage organizations to sign up for CMS email alerts or check the CMS website frequently as updates are occurring at a face pace. Below are some of the common telemedicine visits that may be performed during the public health emergency, but not an all-inclusive list. The comprehensive list of services normally covered by CMS and those services temporarily added for the duration of the public health emergency, please visit the CMS telehealth website at CMS Telehealth Services and download the zip file.
Visits with patients via telemedicine may be billed with codes 99201-99215 and append modifier 95 indicating a telemedicine visit. This service is a synchronous audio-visual visit between the patient and clinician via such services as Skype for Business, Updox, VSee, Zoom for Healthcare, Doxy.me, Google G Suite Hangouts, or Google Duo. During the public health emergency, Facetime, Skype, or Zoom may also be used. However, the Office for Civil Rights has stated that physicians should NOT use Facebook Live, Twitch, TikTok or other public facing communication services.
These services should be billed with the “Place of Service (POS) equal to what it would have been had the service been furnished in-person” according to The Centers for Medicare and Medicaid Services Medicare Learning Network guidance published April 3. Physicians need to follow all other guidelines for documenting and choosing the appropriate E/M service.
Office or other outpatient visit for the evaluation and management of a new patient
Office or other outpatient visit for the evaluation and management of an established patient
Virtual check-in service for your patients is defined as a brief visit if they have an established relationship with a physician or individual practitioner and when the communication is not related to a medical appointment within the previous seven days and does not lead to a medical visit within the next 24 hours. The patient must verbally consent to use virtual check-ins, and the consent must be documented in the medical record before the patient uses the service. Beginning January 1, 2020 physicians may obtain a single consent for a year’s worth of these services:
Remote evaluation of recorded video and/or images submitted by an established patient
Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional
Qualified nonphysician healthcare professional online assessment, for an established patient
Qualified nonphysician healthcare professional online assessment service, for an established patient
On-line Digital Evaluation and Management Service
Physicians also have the option to communicate with their patients via online patient portals. Just like virtual check-ins, communication must be initiated by the patient. Although the services need to be initiated by the patient, the CMS has indicated physicians can educate patients on the availability of this service prior to the patient requesting this service. For either patient virtual check-ins or communication via a patient portal with the physician, the Medicare coinsurance and deductible would apply.
Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes
Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more visits
Appropriate modifiers to be appended based on service performed and payer guidelines:
Synchronous Telemedicine Service Rendered via Real-Time Interactive Audio and Video Telecommunications System
Cost sharing waived
Telehealth services furnished for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke
Via interactive audio and
video telecommunications systems
Via an asynchronous telecommunications system
*Modifier CS- This modifier was announced in early April. The modifier is effective retroactively to March 18, 2020 based on two laws recently passed requiring private health insurers to comply and provide 100 percent payment with no patient cost sharing in these instances. There is no cost sharing allowed for COVID-19 testing or for the evaluation visits related to the testing. Medicare instructs the use modifier CS on the visits and tests, and also recommends contacting your MAC and request to resubmit applicable claims with dates of service on or after March 18, 2020 with the CS modifier if appropriate.
For coders trying to navigate through the changes happening daily, the best thing to do is review CMS and commercial payer guidance frequently. Payers appear to be doing a good job staying on top of updating their policies to reflect the changing environment, so review guidance continually, educate your physicians, and stay healthy!
Karla VonEschen is a coding analyst at 3M Health Information Systems.
During a pandemic, healthcare information is gathered, studied, and published rapidly by scientists, epidemiologists and public health experts without the usual processes of review. Our understanding is rapidly evolving and what we understand today will change over time. Definitive studies will be published long after the fact. 3M Inside Angle bloggers share our thoughts and expertise based on currently available information.