Urology Coding Alert

Plus: Be sure you are submitting the correct CPT^® code as well.

As technology evolves, physicians and other providers learn more ways to connect with patients remotely, whether it’s verifying that something has been added to the patient’s chart or talking to a patient over the phone. This type of service – known as telemedicine – will have a new modifier in 2017 that can help capture your provider’s work better than in the past.

Background: Physicians have questioned how CPT^® should capture telemedicine services for many years. The CPT^® Editorial Panel also has considered the issue for quite some time, according to experts such as David A. McKenzie, CAE, reimbursement director for the American College of Emergency Physicians inIrving, TX.

A joint CPT^® and the Relative Value Units Update committee (RUC), Telehealth Services workgroup was charged with making a recommendation on how best to move forward. The group considered options such as creating a separate set of telemedicine codes to describe services or procedures provided using telemedicine technology or adopting a modifier approach, which could be appended to existing codes to signify that the service was provided via telehealth technology.

Meet the New Modifier in January

The release of the 2017 CPT^® book unveils the workgroup’s decision: the modifier approach. Beginning Jan. 1, 2017, modifier 95 (Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system) will be available for applicable telemedicine claims.

Important: As you can see from the modifier descriptor, the service must be synchronous, meaning in real time, for correct reporting. That means the qualified provider must be using real time audio and video telecommunications between the patient and the distant site in which they practice, and the totality of the information exchanged must be commensurate with the key components or other requirements to have reported the service as if the distant provider was physically present with the patient.

The CPT^® Editorial Panel considered, but apparently chose not to include, a second new modifier for asynchronous (… not real time interaction) services, perhaps because of a lack of specificity for the services with which the modifier would be used. CMS has had HCPCS modifier GT (Via interactive audio and video telecommunication systems) available for use, but 95 is a new modifier for CPT®, says McKenzie.

Also new: CPT^® 2017 will include a new Appendix P, which lists codes that may be used for reporting synchronous telemedicine services when using interactive telecommunications equipment that includes, at a minimum, audio and video. The codes listed in Appendix P will now be marked with a star symbol (H), where they appear normally in the 2017 CPT^® book. For example, Category III code 0188T (Remote real-time interactive video-conferenced critical care, evaluation and management of the critically ill or injured patient; first 30-74 minutes) would be a code that potentially qualifies for modifier 95, but as a Category III code there would be no payment.

The codes selected for inclusion in Appendix P were based on a search of payer policies requiring the use of the HCPCS Level II synchronous modifier with CPT^® codes. Appendix P includes codes describing the following types of service:

• Psychiatric
• Psychotherapy
• Psychoanalysis
• Pharmacy management
• ESRD
• Ophthalmological remote imaging for detection of retinal disease
• Cardiovascular monitoring and telemetry
• Genetic or neurobehavioral assessments
• Medical nutrition
• Office, subsequent hospital, outpatient consult, inpatient consult, subsequent nursing facility, or prolonged services
• Behavioral change interventions
• Transitional care management codes.

Verify You Have the Correct Code

When your physician or qualified non-physician practitioner (NPP) provides some type of telemedicine service, be sure you assign the correct procedure code. In addition to using modifier -95 for telemedicine services, there are several other options one may consider.

Option 1: If you are referring to a phone call, most payers do not recognize codes 99441 (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, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion) through 99443 (… 21-30 minutes of medical discussion).

Option 2: If you are referring to online medical evaluations, several payers recognize code 99444 (Online evaluation and management service provided by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient or guardian, not originating from a related E/M service provided within the previous 7 days, using the Internet or similar electronic communications network). Check with each payer to see its stance on 99444 before filing the claim.

Option 3: If you are referring to telemedicine visits where the patient is in a remote location and the provider is conducting the visit with two-way video and audio communication, you may choose from G0425 (Telehealth consultation, emergency department or initial inpatient, typically 30 minutes communicating with the patient via telehealth) through G0427 (Telehealth consultation, emergency department or initial inpatient, typically 70 minutes or more communicating with the patient via telehealth) for Medicare payers and payers that follow Medicare.

Medicare designed these codes specifically for patients unable to make it to the office because of distance. You’ll use these codes mostly for usually initial office visits, emergency room services, or initial inpatient visits.

Be aware: Practices are using telemedicine more commonly as technology advances—and many regulators are pushing for tighter telemedicine guidelines.

“Telehealth and telemedicine are another stage in the ongoing evolution of new models for the delivery of care and patient-physician interactions,” says AMA Board Member Jack Resneck, MD. “The new AMA ethical guidance notes that while new technologies and new models of care will continue to emerge, physicians’ fundamental ethical responsibilities do not change.”