Pediatric Coding Alert

Take your services out of the office with appendix P.

The healthcare field changes rapidly, and nowhere have those change been so evident than in the field of telemedicine. With the addition of Appendix P to 2017's CPT^® manual, the American Medical Association (AMA) opened the doors wide for this form of service.

With this change, coders have new terminology to deal with, new modifiers to understand, and new concepts to apply to coding. So, we rounded up two of our experts to discuss the implications of telemedicine coding in the field of pediatrics.

Here's what they told us.

So, what is telemedicine anyway?

First, some definitions. Donelle Holle, RN, President of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana, reminds coders that "according to CPT^® guidelines, the service has to involve, 'electronic communication using interactive telecommunications equipment that includes, at a minimum, audio and video.'"

The Centers for Medicare and Medicaid Services (CMS) also stipulate that the communication should be in real time between a patient located in an originating site (such as 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, or a federally qualified health center) and a practitioner (such as a physician, a nurse practitioner [NP], a physician assistant [PA], or a clinical nurse specialist) in a distant, or remote, site (Source: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf).

Why should peds practices care?

For Jan Blanchard, CPC, CPMA, pediatric solutions consultant at Vermont-based PCC, "telemedicine in the pediatric setting is helpful whenever discussion dominates care." For example, Blanchard continues, "patients suffering from ADHD, bedwetting, headaches, diabetes, or any condition where the patient's behavior can help establish patterns, can check in with the physician remotely just as well as coming into the office."

"Another benefit of telemedicine in a pediatric setting," according to Blanchard, "is that it can extend mental health care to patients who go away to college."

Under this scenario, the patient could go to an originating site, such as the college's health clinic, and contact her pediatrician from there. This would allow continuity of care and would not require the patient to change providers during a difficult transition, Blanchard argues.

What's in Appendix P?

You can bill 79 regular CPT^® codes as telemedicine services, Holle notes, including "all the sick visit codes, hospital subsequent care codes, outpatient and inpatient consultation codes, and transitional care management services." So, you are now able to use some of your most-used in-office codes for remote services, such as

• 99201-99205 - Office or other outpatient visit for the evaluation and management of a new patient ... or 99211-99215 Office or other outpatient visitfor the evaluation and management of an established patient ...
• 99231-99233 - Subsequent hospital care, per day ...
• 99241-99245 - Office consultation for a new or established patient...
• 99251-99255 - Inpatient consultation for a new or established patients ...
• 99495 - Transitional Care Management Services with ... Medical decision making of at least moderate complexity ... within 14 calendar days of discharge and
• 99496 - Transitional Care Management Services with ... Medical decision making of at least high complexity ... within 7 calendar days of discharge

But Appendix P also lists some less obvious codes that you could use for telemedicine, including 99406 and 99407 (Smoking and tobacco use cessation counseling visit ...) and 99408 and 99409 (Alcohol and/or substance (other than tobacco) abuse structured screening ...).

Modifier 95, GT, or GQ?

Holle reminds coders that they "have to use the modifier 95 (Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system) to indicate they are telemedicine services. But coders can easily confuse modifier 95 with two HCPCS Level II modifiers - GT (Via interactive audio and video telecommunication systems) or GQ (Via asynchronous telecommunications system).

All look similar, but each one has a different function. Modifier GT is used in conjunction with HCPCS code Q3014 (Telehealth originating site facility fee) and should be used by the originating facility only, while GQ is for asynchronous communication, such as email or text.

Where could I get disconnected when coding telemedicine?

Blanchard also reminds coders that not all synchronous communication can count as telemedicine. However, "providing the discussion is not related to a service performed in the past seven days, and the telemedicine service resolves the issue and does not require an additional, in-person appointment," most E/M-related discussions are billable.

Holle also notes that "before your office determines to use these services - when talking to a young person in college via SKYPE, for example - I would strongly recommend you contact your payer for their guidelines regarding the patient's location and for their advice on reimbursement." And even if your claims do end in denial, Blanchard concludes, practices should keep billing so that payers will notice and rethink their payment policies, letting practices appeal or rebill for the services at some future time.