Pediatric Coding Alert

Question: Our pediatrician tried to conduct a telehealth evaluation and management (E/M) visit with a family, but we could not connect using video and had to perform the service as audio only. As we did our due diligence, and tried to use audio but failed, can we bill an office E/M anyway? Additionally, if we started an E/M visit with video and audio but lost the video part way through, can we bill this as an office visit? Or do we have to bill this as a telephone visit?

Oregon Subscriber

Answer: According to the Centers for Medicare & Medicaid Services (CMS) list of telehealth services for 2021, found at www. cms.gov/Medicare/Medicare-General-Information/Telehealth/ Telehealth-Codes, 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) services must be provided using video and audio. Audio-only E/M services must be billed using telephone codes 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 …).

When a provider attempts a video connection but it cannot be achieved, or when the video connection drops during the service and the service has to be finished as audio-only, the American Academy of Family Physicians (AAFP) recommends using a telephone code “if the visit is conducted primarily via audio” (Source: www.aafp.org/family-physician/patient-care/current-hot-topics/recent-outbreaks/covid-19/covid-19-telehealth/telehealth-faqs.html).

This suggests that if the video was lost after a provider had already conducted a substantial portion of the service, you could probably bill an E/M rather than the phone code, but that would depend on the payer’s definition of “primarily.” A statement in your documentation along the lines of “after obtaining the history and exam portion of the visit, video was lost and the remainder of the assessment and plan with the patient/parents was performed via audio” would help your claim in this instance.