EM Coding Alert

Make modifier mistakes a thing of the past.

Virtual check-ins. POS modifiers. There’s a lot to understand when coding telehealth. And during this public health emergency (PHE), it’s more important than ever that you get it right.

Take a look at these three typical telehealth encounters, and see how they can help you navigate Medicare and private payer guidelines pre- and post-PHE.

Scenario 1: A patient with a simple medical condition describes the condition to a provider in real time using a secure two-way video and audio platform. The physician diagnoses the patient’s condition, offers a plan of treatment, and prescribes medication.

How to code this: Code this as telemedicine using the appropriate E/M service from 99201-99215 (Office or other outpatient visit …). Per the Centers for Medicare & Medicaid Services (CMS) telehealth guidelines during the PHE, you would use modifier 95 (Synchronous telemedicine service …) along with the appropriate place of service (POS) code to reflect where the service would have been provided if done in-person. Pre-PHE, CMS required POS 02 (Telehealth) and no modifier, while some commercial payers wanted you to use POS 11 (Office) if that is where your provider provided the service.

Why? These services are “typically provided in-person, but CMS has agreed to pay if provided using two-way audio and video real-time technology,” according to Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

This means patient and provider must use “interactive audio and video telecommunications system that permits real-time communication between [the provider] at the distant site, and the beneficiary at the originating site (Source: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf). You can find a list of pre-PHE telehealth services, which cannot be conducted via telephones or e-mail systems, listed on the Medicare Telehealth Code List at: www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes. (Payers who use CPT^® codes will recognize the codes found in Appendix P of the CPT^® manual.)

If CMS reverts to its pre-PHE guidelines, then the services must also meet Medicare’s originating site and geographic guidelines, which stipulate the patient must present in an originating site limited to a physician’s office, a hospital, a critical access hospital (CAH), a hospital- or CAH-based renal dialysis center or satellite, a rural health clinic, a federally qualified health center, a skilled nursing facility, or a community mental health center and in “a county outside of a Metropolitan Statistical Area [MSA] or a rural Health Professional Shortage Area [HPSA] located in a rural census tract” per the Telehealth Fact Sheet.

Modifier moment: For services provided by store-and-forward technology (which Medicare only permitted in their Alaska and Hawaii federal telemedicine demonstration programs pre-PHE), you would append modifier GQ (Via asynchronous telecommunications system). Modifier GT (Via interactive audio and video telecommunication systems) is no longer needed except for Medicare claims billed under CAH method II for institutional claims. Private payers, however, “do not follow the Medicare guidelines and instead use their own guidelines for coverage and payment of telehealth services,” Moore notes.

Coding alert 1: Before the PHE, Medicare acknowledged important exceptions to these originating site restrictions:

• Patients with a substance abuse or co-occurring mental health disorder diagnosis can receive telehealth treatment from any originating site other than a renal dialysis facility, including the patient’s home.
• Patients who have suffered an acute stroke can receive telehealth treatment “in any hospital, critical access hospital, mobile stroke units (as defined by the Secretary), or any other site determined appropriate … in addition to the current eligible telehealth originating sites” (Source: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10883.pdf).
• Patients enrolled in Medicare Advantage can receive telehealth services from their homes instead of having to go to one of the listed originating sites.
• Patients in hospital-based and CAH-based renal dialysis centers, renal dialysis facilities, and beneficiary homes where practitioners furnish monthly home dialysis end-stage renal disease (ESRD)-related medical evaluations.

Scenario 2: An established patient calls her physician to discuss a recent asthma exacerbation. The physician discusses ways the patient can cut back on her current levels of strenuous physical activity.

How to code this: Code this as a telephone service using 99441-99443 (Telephone evaluation and management service by a physician or other qualified health care professional …) or as a virtual check-in using G2012 (Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional …). You would select the appropriate telephone services code based on time.

Why? 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.

Coding alert 2: 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.

Pro coding tip: For telephone communications with qualified nonphysician healthcare professionals (QNHPs), such as physical or occupational therapists, clinical psychologists, or speech language pathologists who cannot perform and bill for E/M services, you would use 98966-98968 (Telephone assessment and management service provided by a qualified nonphysician health care professional …), again dependent upon time.

Scenario 3: An established patient and your provider exchange secure digital messages clarifying some nutrition and exercise guidelines following a type 2 diabetes diagnosis several months earlier.

How to code this: For providers who can perform and bill for E/M services, you would use 99421-99423 (Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days …) dependent upon time. For QNHPs who cannot perform and bill for E/M services, you would use either 98970-98972 (Qualified nonphysician health care professional online digital assessment and management, …) or G2061-G2063 (Qualified nonphysician healthcare professional online assessment and management …), again dependent upon time and payer preference.

Just make sure that the service did not originate from, or initiate, a related E/M service either seven days before or after the contact. If so, the work involved in the e-visit is incorporated into the separately reported E/M. You should also add an appropriate POS code per payer preference and pre-PHE guidelines for all virtual check-in and e-visits.

Coding alert 3: Also, per pre-PHE guidelines, the patient must be established and has initiated the contact before you can use 99441-99443, 98966-98968, and G2012. The Interim Final Rule, however, removes this requirement for G2012 while relaxing enforcement of the “established patient … aspect of the code descriptors” for 99421-99423 and G2061-G2063 (Source: s3.amazonaws.com/public-inspection.federalregister.gov/2020-06990.pdf?utm_medium=email&utm_campaign=pi+subscription+mailing+list&utm_source=federalregister.gov).