General Surgery Coding Alert

During the public health emergency (PHE) related to the COVID-19 pandemic, CMS has issued expanded criteria for covering telehealth services, no longer limiting payment to “traditional” telehealth services for beneficiaries originating at a healthcare office in rural areas.

That means your surgeons and associated healthcare providers such as physician assistants (PAs) and nurse practitioners (NPs) may be able to bill regular E/M services even when they take place using an audio-visual device such as a computer or smartphone instead of in person.

“These changes allow seniors to communicate with their doctors without having to travel to a healthcare facility so that they can limit risk of exposure and spread of this virus,” said CMS Administrator Seema Verma. “Clinicians on the frontlines will now have greater flexibility to safely treat our beneficiaries.”

Code for Telehealth Visits

Based on CMS guidance issued on March 17 and March 30, and on language in the COVID-19 interim final rule published in the Federal Register on April 6, here’s what you need to know about performing and billing for telehealth visits for Medicare beneficiaries, effective March 1:

Which codes: If you perform a telehealth visit and you plan to bill your Part B payer for it, you should report these services using the same codes that you would use if you were seeing the patient in another setting. For surgeons, a common situation might be using telehealth via a smartphone instead of an office visit, which you should report using a code from the range 99212-99215 series (Office or other outpatient visit for the evaluation and management of an established patient …) for an established patient or 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient …) for a new patient.

During the PHE, CMS allows healthcare providers to bill telehealth visits for patients at other locations, including some hospital visits and even home visits for a homebound patient. For instance, you should report a home telehealth visit using the appropriate code from range 99341-99345 (Home visit for the evaluation and management of a new patient …) for new patients or 99347-99350 (Home visit for the evaluation and management of an established patient …) for established patients. You can download the entire code list of covered telehealth services from CMS at www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes/.

Communication: To bill a telehealth service using the regular E/M codes, the patient must use “an interactive audio and video telecommunications system that permits real-time communication between the distant site and the patient …,” according to CMS. Your practice can most easily meet the requirements for a telehealth service using a smartphone or computer and an app. There are HIPAA-compliant apps that are integral to many electronic health record (EHR) systems, in addition to standalone apps, such as Doxy.me and Chiron. Furthermore, the COVID-19 expansions of services and HIPAA waivers now allow practices to use more common interactive applications such as Facetime and Skype.

Not telephone: You should not bill the above-referenced codes if your surgeon performs an audio-only interaction with the patient (a phone call). The CMS list of covered telehealth services includes an indicator if you can bill the code for an audio-only encounter, and most E/M codes a surgeon would use are not eligible.

MDM: For telehealth, it appears 2021 has come early, says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a physician and former CPT^® Editorial Panel member in Pasadena, California. “During the COVID-19 emergency, the office E/M level selection can be based on medical decision making (MDM) or time,” he says. However, for COIVID-19 telehealth coding, MDM will be based on the current definition of MDM and the existing MDM tables. Similarly, for time-based coding you should refer to the typical times associated with the 2020 office/outpatient E/M codes.

Note: Read about changes for reporting E/M services in 2021 in “Update E/M 2021: Focus on MDM and Time Next Year” in this issue of General Surgery Coding Alert. Also look to next month’s issue for information about other telemedicine billing options, like virtual check-ins, e-visits, remote monitoring, and telephone calls.

Understand Modifiers

CMS notes that there are several modifiers you should consider for your telehealth claims, advises Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania:

• 95 (Synchronous telemedicine service rendered via a real-time interactive audio and video telecommuni­cations system)
• GQ (Via asynchronous telecommunications system)
• GT (Via interactive audio and video telecommuni­cation systems)
• G0 (Telehealth services for diagnosis, evaluation, or treatment, of symptoms of an acute stroke)

Medicare Part B requires you to use modifier 95 on telehealth claims during the extent of the PHE. Some commercial payers also require modifier 95 for telehealth services, so contact individual payers for guidance.

You might use one of the remaining three modifiers based on circumstantial and/or location considerations.

According to CMS, you should report modifier GQ only when the telehealth service is furnished “via asynchronous (store and forward) technology as part of a federal telemedicine demonstration project in Alaska and Hawaii.” Furthermore, modifier GT is designated for billing under Critical Access Hospital (CAH) Method II. Modifier G0 may be used universally among providers and locations so long as the criteria for the modifier has been met.

Follow Correct POS Instruction

When you bill Medicare telehealth services during the PHE, you should report the place of service (POS) as the place referenced in the code you’re billing. In other words, the POS is the place where the face-to-face visit would have occurred if the provider was not performing a “nontraditional” telehealth service during the PHE.

That means you should bill an office visit performed over telehealth under the PHE with POS of 11 (Office), even though the provider and patient may be communicating from their respective homes. For telehealth claims that a provider would typically perform outside of the office, you’ll want to make sure to use the correct POS code for the respective location. For instance, emergency room visits will require a POS of 23 (Emergency room – hospital) and subsequent hospital visits will require a POS of 21 (Inpatient hospital).

Avoid confusion: Don’t use POS 02 (Telehealth) for nontraditional telehealth services during the PHE. You should reserve POS 02 for traditional telehealth claims for beneficiaries in rural areas with the telehealth service taking place at an “originating site.”

Pricing: For traditional telehealth, Medicare pays the “originating site” the facility fee, leaving the provider with a reduced fee that takes out the overhead paid to the originating site. Since providers are still incurring overhead and there is no facility fee paid to an originating site, CMS has determined that the reduction in the fee schedule is not justified for non-traditional telehealth billed with modifier 95 during the PHE.

Editor’s note: Information related to COVID-19 is changing rapidly. This information was accurate at the time of writing. Be sure to stay tuned to future issues of General Surgery Coding Alert for updates, including more information on other telemedicine services Medicare covers, such as virtual check-ins, E-visits, telephone visits, and more. You can also refer to payer websites, CMS (cms.gov), CDC (cdc.gov), and AAPC’s blog (www.aapc.com/blog) for the most up-to-date information.