Primary Care Coding Alert

Here’s what some experts believe will stay and what will go.

Now that the COVID-19 public health emergency (PHE) is starting to wind down, the question on every coder’s mind is, “what will telehealth look like in the months and years to come?” Some believe the policies that were rapidly put in place at the beginning of the PHE will stay. Others have speculated that telehealth regulations and reimbursement will go back to their pre-PHE states.

Regardless of what happens, understanding payer guidelines and proper documentation techniques will still be important components of successful telehealth programs once the PHE ends, according to Stephanie Sjogren, CPC, CPMA, CCS, CPC-I, CDEO, HCAFA, director of medical coding and provider reimbursement at ConnectiCare in Bristol, Connecticut.

Here, we outline those best practices, along with some predictions about the future of telehealth, taken from her recent HEALTHCON 2021 presentation, “Telemedicine: Achieving Documentation and Coding Success.”

Checking Medicare and Private Payer Policies

First, you will need to keep looking at the fine print. “Some payer policies state they cover telehealth, but before you start up your telehealth program, you need to do your research,” Sjogren warned. That means finding out:

• If your payer will let you render telehealth services and reimburse you;
• If your payer has turned telehealth over to a vendor and, if so, whether that arrangement is exclusive (even if it is, you may be able to ask for an exception if you can show your program will have value and be cost efficient);
• Your payer’s requirements for HIPAA compliance; and
• Your payer’s other telehealth policies, including what services will be covered; what providers will be eligible to provide telehealth services; how you should document telehealth services, including what modifiers and place of service (POS) codes you should use; whether there will be geographic and originating site restrictions; and whether you need out-of-state licensure.

Telehealth Documentation Best Practices

Simply put, “telehealth documentation should not be any different than any other in-person visit,” according to Sjogren, though you should be sure to note the modality (video and audio, audio only, or asynchronous message/data) in order to justify the CPT^® code billed. Additionally, you will need to show that the patient consented to telehealth, which means keeping an annual consent form on file and referring to it in the note — and noting that your physician was able to verify that the person being seen/spoken to during the virtual encounter was the patient or the patient’s parent/ caregiver.

“This means the record should contain statements like: ‘This visit was conducted using synchronous audio/video with Mom and patient present. Mother understands that the exam will be limited and may require the patient to present in person after the telemedicine visit. Mother voiced understanding and gave consent for this type of visit. History presented by mother and patient,’” says Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

Reviewing/Auditing Documentation

In addition to documenting all the above, the record needs to verify that the telehealth provider is qualified to provide the service. Also, for office/outpatient evaluation and management (E/M) services furnished virtually, you will need to make sure the code you select matches the level of medical decision making (MDM) or time documented. “If you are billing using the office visit codes 99202-99215 [Office or other outpatient visit for the evaluation and management of a new/established patient …], you should also have an appropriate history and exam pertinent to the chief complaint and presenting problems, but the level of care will still be based on MDM or time based on CPT^® guidelines,” advises Holle.

Telehealth During the PHE

Currently, the Department of Health and Human Services (HHS) has relaxed many telehealth rules and regulations to allow for safe and flexible healthcare delivery during the PHE. They include such waivers as expanding the number of services allowed, allowing the patient’s home to be an originating site, and “allowing telehealth to be conducted on video-enabled phones using Facetime and Zoom, even when these are not considered to be ‘secure’ but more available for parents/ patients,” Holle notes.

The current Medicare rules also require you to bill for telehealth using the place of service (POS) code you would have used if the service had occurred face-to-face, such as POS 11 (Office), rather than POS 02 (Telehealth). And they also require modifier 95 (Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system) to be appended on real-time services that are on the Centers for Medicare & Medicaid Services’ (CMS’) current telehealth list (found at www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes).

Right now, the PHE has been renewed for another 90-day period, which started on April 8 and will end on July 8 (Source: www.phe.gov/emergency/news/healthactions/phe/Pages/opioids-7April2021.aspx). The waivers connected to the PHE have likewise been extended. What will happen after that remains unclear.

Telehealth After the PHE — What Will Stay the Same and What Will Change

“Many of these new telehealth policies may remain after the PHE,” Sjogren believes, but the following policies, in her estimation, will revert back to pre-PHE state:

• Rurale/sit locations will probably stay the same “because Congress must act for the changes to become permanent for Medicare,” Sjogren notes;
• “Providing telehealth using non-HIPAA-compliant software such as Facetime or Skype will terminate after the PHE,” Sjogren believes;
• “POS 02 will likely resume usage, and payment for telehealth services provided in the office will be adjusted back to the facility rate,” Sjogren also believes.

Private payers “will probably continue to pay for these services, possibly at a lesser amount as they are not in person, as they have realized that these services have become vital to the healthcare community. Delivering services with a phone call or audio/video service can cost the insurance carrier less than the patient going to the emergency department. And with many offices now having portals to communicate with the patient/caregiver, e-visits will more than likely continue to be reimbursed, though again possibly at a lesser amount,” Holle concludes.