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Part B Insider (Multispecialty) Coding Alert

Part B Coding Coach:

Catch The E-Wave- Is Your Practice Wiping Out On Reimbursable Visits?

Published on Wed May 04, 2005

Medicaid and some private payers reimburse for e-visits and telemedicine

When your physician provides services to a patient via the Internet or other electronic means, he saves both himself and the patient time and effort by avoiding a face-to-face office visit. But even though the visit isn't face-to-face, you still deserve reimbursement in many instances - you just need to know how to bill correctly.

Here's the expert scoop on how you can code and get paid for some of your physician's electronic and video communications with patients.

Understand E-Visits

Electronic communications between physician and patient come in two types: online E/M services and telemedicine. Online E/M visits, consultations and Web-visits all fall under the term "e-visit," which is "a structured non-urgent consultation between a doctor and an established patient conducted over the Internet," says Linda Bishop, CPC, CSS, CHC, corporate compliance officer for the Pediatric Management Group in Los Angeles.

History: A code to recognize e-visit services became available last July, when the AMA released 0074T  (Online evaluation and management service, per encounter, provided by the physician, using the internet or similar electronic communications network, in response to a patient's request, established patient). 0074T is a Category III code, which means physicians must report the service even though Medicare considers e-visits "emerging technology" and will not pay for them. According to CPT guidelines, "this service should not be reported for patient contacts  (e.g., telephone calls) considered to be pre-service or post-service work for other E/M or non E/M services ," and the physician must have an electronic or hard copy of the encounter.

A number of private carriers currently cover e-visits. Empire Blue Cross Blue Shield now offers coverage for "online office visits." Under this policy, physicians receive between $20-25 for the Web-visit, plus a $5 copay from the patient, says Karen Earley of Empire Blue Cross Blue Shield in New York. This service is for established patients, particularly patients who have chronic problems such as diabetes or high blood pressure, Earley notes.

Examine These E-Visit Examples

Physicians can use e-visits in a number of ways to help their patients. Study these examples - and don't forget that patient information should come from established patients and go though a secure, HIPAA-complaint site with encryption.

Example #1: A 52-year-old male patient (non-Medicare) suffering from hypertension is taking a new medication to control his condition and is experiencing dizziness, nausea, and fatigue. He e-mails his physician about his symptoms, along with a list of his blood pressure readings since changing the medication. He inquires if he should come in for an office visit or if they should change his medication. The physician reviews the patient's symptoms along with his chart history and pressure readings and suggests the patient is suffering from rare side effects to the medication. He replies to the patient's e-mail and directs him to online information on the drug.  The physician also tells the patient he is calling in a new prescription that will not cause these side effects.

You would code this visit with 0074T and list the appropriate hypertension diagnosis code, such as 401.x (Essential hypertension), along with 995.2 (Unspecified adverse effect of drug, medicinal, and biological substance).

Example #2: A 22-year-old female patient e-mails her physician requesting information on breast cancer after learning several female family members developed the disease. The patient asks if she should get a mammogram. The physician responds to the email and explains the implications of family breast cancer history and gives his opinion as to whether a mammogram is necessary. The physician refers the patient to several online sites on the subject and attaches several documents on the subject that she regularly gives her patients.

You would report this patient interaction with 0074T and V16.3 (Family history of malignant neoplasm; breast).

Don't do this: Unable to reach his physician by phone, a patient e-mails his physician's office email address from his work email account to ask for results of his recent STD test. The physician replies to the patient's email explaining that he's contracted syphyllis and should immediately make an appointment for treatment and counseling on the condition. Because both physician and patient used unencrypted e-mail, parties who should not have access to this medically sensitive information may be able to access it.

When using e-mail to communicate with patients, remember these important guidelines:
 

  •  Communications should be with established patients in non-urgent circumstances only;
     
  •  You must keep a copy of the exchange, either on paper or on a hard drive; and
     
  •  Appointment reminders, prescription refill requests and lab results are not services that you may classify as e-visits. "If you're going to bill for it, it shouldn't be an administrative transaction like that," says Daniel Z. Sands, MD, of Beth Israel Deaconess Medical Center in Boston.

    Remember: If you're using unencrypted e-mail, you should not include personal health information (PHI) by avoiding discussion of "things like HIV, STDs, substance abuse, domestic violence, and psychiatric illness," Sands cautions.

    Use Telemedicine to Diagnose at a Distance

    Although Medicare currently does not reimburse for 0074T for e-visits, both Medicare and Medicaid will pay for telemedicine under certain conditions. Telemedicine is "the evaluation, diagnosis, and treatment of patients at a point of care distant from the provider using video and other electronic media," explains Bishop. Unlike an e-visit, telemedicine is a real-time consultation.

    "Medicare regularly reimburses radiologists, pathologists, and cardiologists who remotely interpret images and EKGs...while Medicare reimbursement is generally much more limited for [telemedicine] E/M services," says Bishop. However, Medicaid regularly reimburses for telemedicine services in a number of states, including California, Arkansas, North Carolina, Virginia and Texas.

    Code like normal: Unlike e-visits, you code telemedicine visits with the CPT code appropriate for the service - and often attach a special modifier to indicate it is a telemedicine service.

    For instance, Virginia Medicaid covers a variety of telemedicine services, such as consultations (99241-99275), office visits (99201-99215), individual psychotherapy (99804-99809), pharmacologic management (90862), colposcopy (57452, 57454, 57460), obstetric ultrasound (76805, 759810), cardiography interpretation and report only (90310) and echocardiography (99307-8, 99320-1, 99325).

    To bill Virginia Medicaid for telemedicine services, you report regular CPT codes with modifier -GT (Providing visits through the use of interactive audio and video telecommunications system) to indicate it is a telemedicine service. The service reimburses according to the Virginia Medicaid fee schedule, says Jeff Nelson, Policy Analyst with Commonwealth of Virginia's Department of Medical Assistance Services (DMAS), Division of Policy and Research in Richmond.

    Example #1: A dermatologist in Charlottesville examines a patient suffering from eczema using video conferencing to examine the patient's response to a new treatment regimen. Based on the results he sees, the dermatologist recommends that the patient continue the treatment and return in two weeks for follow-up.

    You code: Report the visit with the appropriate-level established patient E/M code, such as 99212, and append telemedicine modifier -GT.

    Example #2: A cardiologist examines a patient suffering from shortness of breath, fatigue, dizziness, and tightness in the chest through video conferencing. A nurse practitioner uses a digital stethoscope to transmit the patient's heart and lung sounds to the cardiologist, who also receives a read-out of the patient's EKG through the Internet and interprets it.

    You code: Report the telemedicine visit with the appropriate new patient E/M code, such as 99203, and list 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only) for the EKG interpretation. You would need to be sure to append modifier   -GT to both codes
    .
    Remember HIPAA compliance: You can make a telemedicine visit HIPAA-compliant by having "every patient sign a consent form," and scrambling or encrypting all of the transmissions between the two sites, explains Joseph C. Kvedar, M.D. vice chair of dermatology at Harvard Medical School and director of Partners Telemedicine in Boston.

    Use Modifiers According to Medicaid Policy

    Other telemedicine modifiers that Medicaid may require are -GQ (Providing visits though the use of asynchronous telecommunications system), and state-specific -CT, -WT and -TR.

    Watch out: Covered telemedicine services and modifiers vary drastically from state to state. Check with your state's telemedicine policy before billing for these services by visiting     www.cms.hhs.gov/states/telelist.asp.

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