Urology Coding Alert

Lay out the groundwork for three more types of virtual services.

Understanding the coding dynamics at play for telehealth services is only half the battle. To be a well-rounded telehealth and telemedicine coder, you’ve got to be prepared to code all forms of virtual services — including those that don’t involve an audiovisual component.

In this article, we’ll look at three forms of virtual services a patient or provider might utilize during this public health emergency (PHE). Furthermore, you’ll get some critical guidance on the use of modifiers, place of service (POS) codes, and other billing considerations.

Fill in the remaining pieces of the puzzle with a complete coding breakdown of virtual check-ins, e-visits, remote monitoring, and more.

See What Sets Virtual Check-Ins Apart

Your first point of order is to properly distinguish between a Medicare telehealth visit and a virtual check-in. A virtual check-in involves a “brief” communication between patient and provider, typically from the confines of the patient’s own home. However, the type of communication modality for a virtual check-in does not involve face-to-face interaction. Rather, patients will bypass the audiovisual means of communication for an audio-only exchange with the provider. This form of service qualifies as telemedicine.

Virtual check-ins are designated for new and established patients of physicians or eligible practitioners “where the communication is not related to a medical visit within the previous 7 days and does not lead to a medical visit within the next 24 hours (or soonest appointment available),” according to CMS in the March 17 press release (https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet).

For your typical Medicare Part B telephone-based virtual check-in that lasts under 10 minutes, you’ll report HCPCS code G2012 (Brief communication technology-based service, e.g. virtual check-in … 5-10 minutes of medical discussion). While the guidelines are shifting during this fluid situation, most commercial payers require that you report the following code set for virtual check-in services:

• 99441 (Telephone evaluation and management service by a physician… 5-10 minutes of medical discussion)
• 99442 (…11-20 minutes of medical discussion)
• 99443 (…21-30 minutes of medical discussion)

For qualified non-physician healthcare professionals (QNHPs) who cannot perform and bill for E/M services, you’ll report code range 98966-98968 for telephone-based services.

Billing update: The interim final rule indicates that CMS will reimburse for 99441-99443 during the extent of the COVID-19 PHE. Additionally, both new and established patients qualify for 99441-99443 reporting to both CMS and commercial payers. This means that for Medicare virtual check-ins that extend beyond the 10-minute mark, you should report code range 99442-99443, depending on time spent communicating with patient. You’ll also want to keep in mind that some commercial payers accept G2012 in addition to 99441. Lastly, keep a look out for information on Medicare retroactive billing for code range 99441-99443 from a specific date in March.

Payer update: Some commercial payers, such as UHC, are allowing providers to report audio-only telecommunication services with E/M office visit code range 99201-99215. Check commercial payer guidelines prior to making your virtual check-in code selection.

Note: Reserve HCPCS code G2010 (Remote evaluation of recorded video and/or images…) for “store and forward” services in which a patient sends a practitioner an image or video and the practitioner responds within 24 hours.

Code E-Visits for Patient Portal Communication

The third type of virtual service you’ll want to consider is an E-visit. On the surface, these services may look similar to virtual check-ins. However, the difference lies with the channel of communication. “E-visits (digital communication) take place through a secure online portal,” relays Natalie Ruggieri-Buzzelli, CPC, CGSC, HIM coding specialist at the Hospital of the University of Pennsylvania.

“E-visits are a patient-initiated encounter between a physician or other qualified healthcare professional. If the inquiry is related to a surgical procedure within a global period, then the service is not reported. The provider must keep a permanent record on file. Other rules apply and are listed in the CPT^® manual,” outlines Ruggieri-Buzzelli.

E-visits are exclusive to established patients and may include time spent for interaction for up to seven days. This means that providers must document the time associated with each interchange in order to add up the time spent at the end of the seven-day period. E-visits may be performed by physicians or advanced practice providers (APPs) using one of the following three time-based E/M codes:

• 99421 (Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes)
• 99422 (…11-20 minutes)
• 99423 (… 21 or more minutes)

Don’t forget: The fourth type of virtual care involves remote monitoring via code range 99453-+99458, in addition to code 99091 (Collection and interpretation of physiologic data…requiring a minimum of 30 minutes of time, each 30 days). This can include remote heart monitoring, blood pressure monitoring, blood sugar monitoring, etc. These services not only provide extensive data to the provider, but also ongoing feedback to the patient.

Round Out Your Knowledge With Modifier Guidelines

There are four modifiers you’ll want to consider for telehealth (audiovisual) code reporting:

• 95 (Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system)
• GQ (Via asynchronous telecommunications system)
• GT (Via interactive audio and video telecommunication systems)
• G0 (Telehealth services for diagnosis, evaluation, or treatment, of symptoms of an acute stroke)

Medicare Part B requires the use of modifier 95 on telehealth claims during the extent of the PHE. Some commercial payer policies also require that you append modifier 95 to telehealth claims. You should check on individual payer guidelines prior to reporting modifier 95 with your claims for non-Medicare Part B payers.

The remaining three modifiers are based on circumstantial and/or location considerations. According to CMS, you should only report modifier GQ when the telehealth service is furnished “via asynchronous (store and forward) technology as part of a federal telemedicine demonstration project in Alaska and Hawaii.” Furthermore, modifier GT is designated for billing under Critical Access Hospital (CAH) Method II. Modifier G0 may be used universally among providers and locations so long as the criteria for the modifier has been met.

Get Some Essential POS Background Knowledge

The place of service (POS) code that you use for telehealth claims should be the place where the service would have been traditionally provided had it been a face-to-face visit. That’s because all telehealth services provided during the PHE are considered “nontraditional” telehealth services.

With a traditional telehealth service, Medicare pays the “originating site” the facility fee, leaving the provider with a reduced fee that takes out the overhead paid to the originating site. Since providers are still incurring overhead and there is no facility fee paid to an originating site, CMS has determined that the reduction in the fee schedule is not justified. This means that an office visit performed over telehealth under the PHE would be billed with a 95 modifier and POS of 11 (Office) for the office, even though the provider and patient may be communicating from their respective homes.

For telehealth claims that a provider would typically perform outside of the office, you’ll want to make sure to use the correct POS code for the respective location. For instance, emergency room visits will require a POS of 23 (Emergency room – hospital) and subsequent hospital visits will require a POS of 21 (Inpatient hospital).

With respect to virtual check-ins and E-visits, you’ll want to report POS code 11, not POS code 02 (Telehealth) for Medicare Part B claims in addition to (most) commercial payers.

You will also report remote physiologic monitoring codes with POS 11.

Disclaimer: Information related to COVID-19 is changing rapidly. This information was accurate at the time of writing. Be sure to stay tuned to future issues of Urology Coding Alert for more information. You can also refer to payer websites, CMS (cms.gov), CDC (cdc.gov), and AAPC’s blog (www.aapc.com/blog) for the most up-to-date information.