General Surgery Coding Alert

Grasp CMS Rules, too.

With advancing technology, you might find your surgeons spending more time connecting with patients remotely using audiovisual communication — a type of telehealth service, also known as telemedicine.

Now you have some new code designations, modifiers, and instructions in 2017 that you’ll need to understand if you want to collect appropriate pay for these services.

Snapshot: The CPT^® Editorial Panel has long considered how to capture telemedicine services, according to experts such as David A. McKenzie, CAE, reimbursement director for the American College of Emergency Physicians in Irving, TX. Now a joint CPT^® and the Relative Value Units Update committee (RUC), Telehealth Services workgroup has moved forward in 2017 with a system using a new modifier and code-designation approach rather than creating dedicated new codes.

Identify Appropriate Codes

CPT^® 2017 creates a new Appendix P that lists 79 codes you can use to report synchronous (real-time) telemedicine services. Also new for 2017, CPT^® identifies the appropriate telemedicine codes with a star (★) symbol next to the code in the code set.

The codes selected for inclusion in Appendix P were based on a search of payer policies requiring the use of the existing HCPCS Level II synchronous modifier (discussed below) with CPT® codes. Appendix P includes codes describing the following types of service, some of which will intersect with your surgery practice:

• End Stage Renal Disease (EDRD) codes 90951-90961
• Cardiovascular monitoring and telemetry codes 93228-93229
• Genetic assessment code 96040
• E/M codes for office, subsequent hospital, outpatient consult, inpatient consult, subsequent nursing facility, or prolonged services
• Transitional care management codes 99495-99496.

Notice requirements: Appendix P instructions state that the electronic communication using interactive telecommunications equipment must include “at minimum, audio and video.”

Use Modifier to Mark Telemedicine

CPT^® 2017 gives you a new modifier to identify when a service your surgeon performs uses telemedicine technology. The modifier is 95 (Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system). You should use the modifier to report real-time video interactions your physician has with patients when they aren’t physically present together.

Important: As you can see from the modifier descriptor, the service must be synchronous — meaning in real time — audiovisual telecommunications, usually conducted via an internet video conferencing platform. To report an Appendix P code with modifier 95, the totality of the information exchanged must be commensurate with the key components or other requirements of the code, just as if the distant provider was physically present with the patient.

Why modifiers? “It’s important for the payers to know if the patient was physically in the office or seen via telemedicine,” says Suzan Hauptman, CPC, CEMC, CEDC, senior principal of ACE Med group in Pittsburgh, Pa. “Because the codes are the same regardless of physical location, the 95 modifier tells this part of the story.”

You also have two HCPCS Level II modifiers that most MACS have required for telemedicine services:

• GT, Via interactive audio and video telecommuni­cation systems
• GQ, Via asynchronous telecommunications system

The difference: Asynchronous communication does not take place in real time. An example would be an e-mail exchange between patient and provider, or communication regarding X ray images transmitted across a secure network.

Glitch: Notice that new modifier 95 has essentially the same definition as existing modifier GT.

As for knowing which modifier to choose for real-time services, “practices should check with their respective payers on telemedicine coverage policies and the use of the appropriate modifier — 95 or GT,” says Mary I Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. All Medicare providers require modifier GT.

Mark Proper Telemedicine POS

If your surgeon performs a telemedicine service, what should you indicate as the place of service (POS) on your claim?

Answer: CMS created a new POS code for telemedicine: POS 02 (Telehealth: The location where health services and health related services are provided or received, through a telecommunication system), according to an MLN Matters article which you can access here: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9726.pdf.

Reminder: You must append one of the telemedicine modifiers to your CPT^® or HCPCS code when you list POS 02 for telemedicine on your claim — if you don’t, you can expect a denial from your MAC. Also, telemedicine services must meet a certain set of rules to be covered for Part B beneficiaries, and you should direct any questions to your carrier for clarification. For a list of the current telemedicine services approved by Medicare, visit (https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.html.

Check Existing Telehealth Codes

If you’re dealing with certain telehealth procedures that you shouldn’t report with modifier 95 because they aren’t part of the new Appendix P, you might be able to turn to some existing CPT® codes to report the service.

Telephone E/M: Although CPT^® provides 99441-99443 (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; … minutes of medical discussion).

Online E/M: Several payers recognize code 99444 (Online evaluation and management service provided by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient or guardian, not originating from a related E/M service provided within the previous 7 days, using the Internet or similar electronic communications network). Check with each payer to see its stance on 99444 before filing the claim.

HCPCS options: For telemedicine visits where the patient is in a remote location and the provider is conducting the visit with two-way video and audio communication in specific care areas, you may choose from G0425 (Telehealth consultation, emergency department or initial inpatient, typically 30 minutes communicating with the patient via telehealth) through G0427 (Telehealth consultation, emergency department or initial inpatient, typically 70 minutes or more communicating with the patient via telehealth) for Medicare payers and payers that follow Medicare.

Medicare designed these codes specifically for patients unable to make it to the office because of distance. You’ll use these codes mostly for usually initial office visits, emergency room services, or initial inpatient visits.

Be aware: Practices are using telemedicine more commonly as technology advances—and many regulators are pushing for tighter telemedicine guidelines.

“Telehealth and telemedicine are another stage in the ongoing evolution of new models for the delivery of care and patient-physician interactions,” says AMA Board Member Jack Resneck, MD. “The new AMA ethical guidance notes that while new technologies and new models of care will continue to emerge, physicians’ fundamental ethical responsibilities do not change.”