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On-Demand: Telehealth and Coding

Dec 9, 2020

During this webinar, we discussed the current status, value, and types of telehealth services, as well as coding and documentation for telehealth visits.


Good afternoon, and welcome to this second in our series of webinars on the critical topic of coding. To briefly review, our agenda will cover the area of focus for today, which is telehealth, how trends in telehealth and COVID and prior are coming together to make telehealth so critical. We will walk through key elements of telehealth and talk some at a transition about the risks to providers in coding. Then I will be handing this presentation over to my colleague, Nancy.

Bert Orlov: As we see, COVID has, in our opinion, accelerated, but not intrinsically changed the trajectory of the demand for telehealth services. So the graph at the bottom shows how during the earliest months of the COVID pandemic, there was an enormous increase in the use of telehealth. That came back down as we approached summer. We don't yet have the detail, but we imagine teat this chart extended out would show a return to a much higher level as the wave two of the pandemic has grown in strength.

Regardless, we think the general pattern will hold at building on the years of interest in telehealth as a key potential modality for healthcare delivery, especially for people in rural areas, the elderly who have difficulty getting to doctors, and people with disabilities. We believe that the baseline for telehealth volumes will stay at a level vastly higher than a year ago, hence the importance of talking about coding in the context of telehealth.

As we describe here, the stage has been set for this growth of telehealth. We won't go through each of the detailed items, but these are some particular data points that support the extraordinary growth in telehealth in 2020. And again, although we anticipate that total volumes will come back down once COVID wave two is under control, we don't believe that telehealth will ever again be relegated to such a secondary position in the universe of care providing. And in part, that is because as we just mentioned, patients have grown more accepting of telehealth, and there are certainly populations that really benefit from the ease of access that telehealth provides.

I'd also like to note as we made a glancing referencing in the prior page about the transition to a Biden administration, all observers conclude that the Trump administration has advanced telehealth in context of the emergency declaration for COVID, and that there is great bipartisan interest in continuing this expansion, yes, with further study as to its clinical efficacy and with a focus on preventing fraud. Nevertheless, we have every reason to assume that the next year will only build on the access to telehealth services.

In particular, we know that last week, CMS promulgated its rules in the MDC schedule, which set into place an expanded array of services, and we'll talk about that in a few moments. And we also acknowledge that there will be need for further legislation, particularly addressing making these changes permanent outside of the emergency declaration, addressing the concerns of crossing state lines and how that will work, extending the use of telehealth services clearly to non-rural areas. But there is, as we said, strong support, bipartisan, for these actions, therefore, we believe that telehealth will occupy some very interesting general and niche roles.

And we want to take a moment or two strategically to talk about them. I think most of us are familiar with the increased use of telehealth, often through smartphones for urgent care services. And certainly during the pandemic, they became a critical component of primary care services. One of the things we note, and there have been a number of articles, some research was just done in Massachusetts showing that small groups are struggling with how to integrate telehealth into their practice. Part of that is strategic, but part of that is the operational coding and documentation that Nancy will describe.

We have seen often when we mention practice supplementary, we're seeing telehealth used for screening visits, for identifying patients who need to actually come into the office in person. We're seeing it in places where we may not have anticipated, such as physical therapy through telehealth, so we again believe many uses, many demands on coding, many strategic implications. We see that most strongly perhaps in behavioral health. In so many parts of the country, the ability to access behavioral health services has been highly constrained by lack of availability of providers in many areas. Telehealth allows for that access. And in particular, we've seen huge spikes in telehealth because of the psychological and behavioral health implications on patients living through the pandemic and reaching out for help.

We think that as a result of the emphasis placed on it by the MD fee schedule, and by the move toward value based care, that monitoring, excuse me, chronic conditions is a critical component of the future of telehealth. The actual existence of remote patient monitoring as an accepted and CPT denominated service by physicians and their practices will become increasingly important in a world where purchasing based on value, as we've come to understand, is increasingly important, therefore, larger and larger numbers of patients will be under more aggressive physician management for their chronic diseases, insofar as management of those diseases enables more cost effective care.

Obvious example, somebody with diabetes who is having frequent spikes, if their condition is monitored more rigorously and medication adjusted appropriately, that should hopefully avoid emergency room visits and potential admissions, both of which are not only costly, but put the patient at risk. And the data at the bottom of this slide emphasizes the projected growth in that area. So coming up with the anticipated growth of telehealth as a permanent part of the healthcare delivery system, not merely a short-term COVID response, we do anticipate the imperative of risk avoidance.

The Department of Justice has already begun looking more aggressively at fraud. We know that CMS is concerned with potential fraud. So it becomes particularly imperative for providers to accurately and properly code and document and bill all telehealth services. Again, the reasons are for the fraud, which is a perceived risk, any individual practice needs to document that's not the case. Strong documentation to ensure protection against malpractice litigation becomes important. And training of the staff, as well as the physicians in somewhat new forms of documentation. This is the point when I hand the conversation over to my colleague.

So in summary, we move finally to the question of risk avoidance in ensuring effective coding and documentation. We've discussed how we anticipate that telehealth will not only stay a part of the healthcare landscape going forward once we're through wave two of COVID-19, but that we can envision numerous ways in specific clinical or ancillary services, as well as for specific populations or geographies that telehealth will only become a stronger component of the healthcare delivery system. Therefore, it becomes imperative that all provider organizations manage the risk and maximize the opportunity from the perspective of coding, and thus, reimbursement. So as we're all aware, there is a high degree of anxiety about fraud related to telehealth. That's been stated by CMS, by DOJ, et cetera. So we have to be very conscious that this is likely to be a microscope focus here.

So without going through all of the details on the slide, which you all can read, we have already seen this uptick in Department of Justice actions. We see payers really looking at claims in detail. We recognize that physicians and staff need more training in how to document these specific services because they haven't been central. And just because provider organizations have managed to get through COVID wave one, and now will likely get through COVID wave two, doesn't mean the practices and policies are where they need to be going forward, especially in light of changing coding requirements.

And finally, this does also correlate to malpractice, which in telehealth becomes more important because documentation needs to meet the required rigors of services delivered in a setting where the patient and the physician are not sitting together. So with that, it is my pleasure to turn the discussion over to my colleague, Nancy Clark. I would take the time to walk you through her credentials, but we only have an hour for this webinar. So therefore, Nancy, to you.

Nancy Clark:Thank you so much, Bert. As we move into the coding portion, we'll take a look at some regulatory updates, types of telehealth services, how the change in E and M guidelines will apply to telehealth, the relatively permanent versus temporary services, compliant documentation of medical records, and review some ways that telehealth can add to your practice's revenue mix.

As of October 2nd, the Centers for Medicare and Medicaid Services, CMS, has extended the public health emergency through January 31st of 2021. This is the third declaration of a public health emergency, the first set in January of 2020, the second in April, and the third in July. This declaration comes with flexibilities and leniency in billing telehealth services, including no limitation to the originating site in which the patient is located, or the distant site in which the provider is located.

Previously, the originating site was limited to a health professional shortage area. Prior to the PHE, the distant site required that the provider be licensed in the state where they are providing services. While state guidelines still preside, CMS waives the requirement that a provider is licensed in the state that he or she is servicing, provided in general that the state is under a PHE. For some services that were previously allowed to be delivered via telehealth, only established patients qualified for the service. Now CMS is allowing new patients to qualify for some of these services. Expansion of allowed testing locations allows for easier access to diagnostic procedures, by allowing more testing at home, or in community based settings.

The Coronavirus Aid, Relief, and Economic Security Act, better known as the CARES Act, further expands services by allowing certain evaluation and management and behavioral health counseling services to be provided by audio only means. And certain educational services are now offered via telehealth. Additional services are added on a temporary basis, including emergency department and initial hospital care. CMS has also removed frequency limits on services, including skilled nursing facility visits and critical care consultations, as well as increasing frequency of subsequent inpatient visits. And end stage rental disease services no longer require a hands on visit each month for the clinical exam of the vascular access site.

The Office of Civil Rights waived all provisions of the HIPAA privacy, security, and breach notification rules if a telehealth provider acted in good faith. This meant for example that a provider did not need to use communications technology to comply with the HIPAA security rule, but instead could use other technologies such as Zoom, FaceTime or Skype, that might not meet all HIPAA requirements, but are nevertheless designed to be non-public facing, which allows only the intended parties to participate in the communication.

While commercial carriers are not required to follow CMS guidelines, most have adopted the major principles, and most have currently extended their flexibilities at least through the end of this year. When someone says, "Telehealth," we usually envision a video chat platform. Two-way video conferencing is quickly becoming a popular alternative to in person doctor visits. But telehealth or telemedicine encompasses a much broader range of healthcare services than just real time medical consultations over video. We can break down telehealth into five major types of services that can be offered to patients.

First, the audiovisual services, these are what we typically think of as telehealth services, the use of interactive telecommunication systems to furnish healthcare services using real time audio video technology. Telephone only services include the expanded services we discussed, such as behavioral health counseling, as well and E and M visits. E visits are a visit by email, or an online portal. And asynchronous telemedicine is also referred as store and forward telemedicine solutions. Remote patient monitoring is also known as tele monitoring, and not always included in the major telehealth bucket of services, but can be integral to chronic disease management.

Audiovisual services create a virtual visit between the patient and the provider. They are the most frequently utilized services with platforms such as TeleDoc and Doxy Me growing in use over the past several months. Included here are evaluation and management, or E and M services, in which the provider evaluates the patient's condition and then manages it or treats it. When documenting these services, care must be given to use the current year guidelines. We will briefly review these guidelines later in the presentation. The added leniency during the public health emergency is the addition of seeing some new patients by audiovisual means.

A new patient is one who has not received professional services from the provider, or another provider in the same group of the same subspecialty within the past three years. Established patients, those who have received services within three years, have previously been covered under telehealth guidelines. There are also newly added places of service in which a provider can virtually deliver care, including observation care, initial hospital and emergency department care. Initial nursing facility and home care have been added as well.

Prior to the PHE, telephone only services were limited to a few brief services, including the Medicare virtual check in, which lasts five to 10 minutes. One of the conditions of billing a virtual check in is that no E and M visit is scheduled in the next 24 hours, or the previous seven days. During PHE, this code can now be used for new or established patients. And additional provider types can perform the service. We can also utilize the CPT codes 99441 through 99443 for a variety of times, from five minutes up to a 30-minute call. These codes are payer specific, so be sure to check for regulations with each payer.

E visits include email or online portal communications. The codes are based on the cumulative time the provider spends on the visit and whether the provider is a physician or a qualified non-physician healthcare professional. The PHE added licensed clinical social workers, clinical psychologists, physical and occupational therapists, and speech language pathologists to the allowed providers. As with telephone visits, ensure that you check the carrier prior to billing the visit.

Asynchronous telemedicine enables healthcare providers to forward and share patient medical data such as lab results, images, videos and records, with a provider at a different location. These platforms offer a kind of sophisticated secure email platform, a way to share patient data online securely. The asynchronous term refers to the fact that the consulting specialist, patient, and primary doctor, don't need to all be communicating at the same time. As a parallel, think about a telephone call versus an email exchange. A telephone call is synchronous and requires all parties to be communicating in real time, whereas an email exchange does not.

Store and forward telemedicine works best for interprofessional medical services, where a provider needs to outsource a diagnosis to a specialist. For instance, tele radiology relies heavily on store and forward technology to allow technicians and healthcare professionals at smaller hospitals to share patient X-rays for diagnosis by a specialist at another location. Asynchronous telemedicine is also commonly used for tele dermatology and tele ophthalmology. Store and forward telemedicine is a great way to increase healthcare efficiency since a provider, patient, and specialist don't need to be in the same place at the same time. It also facilitates faster diagnosis, especially for patients located in underserved settings that may not have the necessary specialists on staff.

As with other remote services, the service can only be billed if it is unrelated to a previous E and M service within the past seven days, and no related E and M service results from the service within 24 hours or the next available appointment. Asynchronous services can also include E visits and be designated by modifier GQ.

Remote patient monitoring, or RPM, allows providers to track a patient's vital signs and other health data from a distance. This makes it easy to watch for warning signs and quickly intervene in patients who are at health risk, or are recovering from a recent surgery, for example. This type of telemedicine is sometimes called tele monitoring or home telehealth. While technically not on the telehealth list, RPM telemedicine is quickly rising in popularity, as more health professionals realize its potential effects on chronic care management.

For instance, a patient with diabetes who has a glucose tracker in their home can measure their glucose levels at regular intervals and transmit them to their doctor. If all is well, those results are simply recorded. If something looks off, the physician may flag it and call in the patient for a consult. Codes exist for electrocardiograms, blood pressure, and glucose monitoring, as well as self-measured blood pressure, which was added during the PHE. Note that these codes are based on documented time and some are billed per month. The PHE allows some new patients to be added to the monitoring.

With the largest change in E and M guidelines arriving in just a few weeks, it will be important to understand which guidelines apply to the date of service being documented. Let's take a look at the differences between the 2020 current guidelines and the 2021 future guidelines and discuss their impact on telehealth documentation and services. Currently, E and M is coded by the medical record's history, exam, and medical decision-making, or MDM. In 2021, either MDM or time is necessary to code E and M levels. Since the exam will no longer be a key component in the documentation, it will no longer have an equal impact on new patient visits, and it may make the documentation for telehealth easier.

The quantification of time has two significant changes. First, face-to-face time will no longer be calculated, but total time will be. That includes the time reviewing the patient's chart prior to the visit and reviewing test results after the visit by the physician. This time must be clearly documented in the medical record. Additionally, the requirement of time being utilized only for counseling or coordination of care no longer exists, which may be a boon to telehealth documentation. And finally, the requirements for documenting and determining medical decision-making changed and are delivered in a new table.

For MDM to be a deciding component in documentation and code selection, it is paramount that providers understand and utilize these guidelines. Otherwise, revenue earned could be subsequently lost to an audit. Let's discuss some general guidelines for billing E and M telehealth visits. Keep in mind that rules vary by carrier, so you should check directly with your carrier to ensure you bill at their guidelines. The place of service does vary, but for CMS and many others, we are directed to utilize the place of service that would have been used if the service had been provided in person. So for an office visit, we would use place of service 11. The logic behind this is at least for the public health emergency, providers are frequently reimbursed at the same rate as though they had delivered the service in person.

Some carriers reimburse the facility rate that would've been paid at a hospital or other inpatient setting. Other carriers may prefer place of service to telehealth. Several modifiers may apply. The most common is 95; synchronous telemedicine service rendered via a real time interactive audio and video telecommunications system. Most recently, Medicare and several major carriers were using 95. GT indicates the service was delivered via synchronous or real time telecommunications. And GQ indicates the service was delivered via asynchronous or non-real time telecommunications. There's also CS, which identifies that cost sharing is waived for COVID-19 related services and may be required at times.

Remember also to fully utilize your providers. Based on the service, a variety of professionals in your office can be utilized to perform the telehealth visit. Current professionals for CMS include physicians, nurse practitioners, physician assistants, nurse midwives, clinical nurse specialists, certified registered nurse anesthetists, clinical psychologists and clinical social workers, who are limited to certain services, and registered dieticians or nutrition professionals.

Now let's address a further breakdown of telehealth services, those that are listed as a regular or permanent service for the calendar year, and those that are temporarily allowed due to the PHE. These are just some highlights of the telehealth codes available for use, primarily the ones I find to be available to many professionals. Understanding the major differences will allow your practice to better plan how to utilize the services to support your patients and add to your revenue mix. Just last week, the CMS 2021 final rule was published. At the time, nine additional codes were added to become permanent for the next year. And additional codes were added to the temporary PHE leniency.

In the E and M category, all office visits and subsequent hospital care and nursing facility care are covered as telehealth services. During the pandemic, initial hospital and nursing facility care are now covered. Home visits for new and established patients are covered with the two lower levels of established patient home visits just moved to the permanent category. And critical care services are covered in order to get the right specialist to the patient at the right time. For all the E and M codes, both audio and visual real time interaction is required. Additionally, behavioral and mental health have several services available for providers to offer their patients.

Psychiatric diagnostic evaluation and psychotherapy with and without E and Ms, interactive complexity, the neural behavioral status exam, and multiple health behavior assessments and interventions, which include health focused clinical interviews, behavioral observations, and clinical decision-making for individuals, groups, and families. These codes are usually time based. For this range of codes, audio only is acceptable. There are many other allowed codes, including smoking and tobacco cessation codes, advanced care planning, medical nutrition therapy, end stage renal disease services, and transitional care planning, all included in the permanent codes.

Other temporary codes for the PHE have expanded to include radiation treatment management, cardiac services, such as continuous ECG monitoring, ventilation management, many PT and OT services, and speech and hearing evaluations. There are additional codes primarily used by Medicare and Medicare Advantage plans, including diabetes training, medical nutrition assessments, alcohol and substance misuse, CKD education, and a time based telehealth inpatient or ED consultation.

Now here's an underutilized code, the annual wellness visit, along with alcohol and depression screening and behavioral counseling. We have pharmacologic management for inpatient, chronic care management, and both critical care and prolonged preventive service codes. We round out at treatment for opioid use disorder. These lists include some, but not all, telehealth services. I strongly advise that you review these codes and understand the requirements to see if your practice can implement some of the services to your patients.

With all these options, it is paramount to have the documentation to support the codes billed. We have already seen audits on telehealth services by carriers and the resulting recruitment of payments. And as Bert noted, the Department of Justice is keeping an eye on telehealth. So let's review the necessities for compliant documentation based on a variety of resources supplied by carriers. The method of communication should be listed in the documentation. One thing the audits are focused on is the specific platform used, such as TeleDoc, or Doxy Me, or a designation of a phone call. Identify the location of both the provider and the patient. Remember that in non PHE telehealth, the originating patient site and distant provider site are required elements of the documentation.

It is also necessary to list all clinical participants if someone other than the provider was present and integral to the patient's care. And if the CPT descriptor requires time, ensure that this is documented, either start and stop time, or total duration. If billing E and M visits by time, this must be noted as well. It is very important to document that the patient has consented to receiving services via telehealth, and any other documentation as required for the CPT code. Remember that telehealth does not excuse you from basic documentation requirements.

Related to compliance, let's briefly discus state parity laws and PHE waivers. While we can't discuss every state, be aware that almost every state has laws regarding telehealth. As of the creation of this presentation, 42 states and DC have parity laws for the services provided, but they vary widely by what is covered and what is reimbursed. Telehealth payment parity laws, which require health plans to pay the same for healthcare delivered remotely as they do for care delivered in person are rare, with only 10 states having anything on the books about similar reimbursement in a telehealth setting. And even those states with laws set payment parity as a baseline.

Providers and plans are still allowed to negotiate rates that differ from this baseline. There are separate laws governing asynchronous healthcare, with 24 states mandating coverage. And 40 states plus several territories have modified their telehealth laws based on the current pandemic. Be sure to verify your state's laws. The references on these pages can direct you to individual state's guidelines.

There are many ways telehealth can add to your practice's revenue mix. For one, patient maintenance and continuity of care, keep in contact with your patient and assist in managing their chronic diseases, even when they may not feel comfortable coming into the office. Keep a patient engaged as they wait for surgery. Consider using remote physical therapy to keep a patient limber prior to orthopedic surgery, for example. And there are a few codes that apply to many providers that are worth considering. First, chronic care management, G0506, is an add on code that is used with chronic care management services, 99487 and 99490. This code is utilized when a provider manages a patient's chronic conditions over a monthly period as an add on to the monthly chronic care services. This includes a higher level of complexity, extensive management, and care planning. It can be billed once per billing practitioner for a given beneficiary at the onset of CCM.

The face to face requirement can be satisfied remotely via audiovisual. Since the base codes don't require face-to-face management, the totality of services can be performed remotely. These codes will benefit those providers who manage patients with multiple chronic disease processes. And the Medicare annual wellness visit, both initially and each year subsequently, these require 10 components, including a health risk assessment, a medical and family history, and a list of current providers and medications. All of these components can be performed remotely. An exam is not part of the AWV. And this visit can be performed in addition to and E and M service on the same date of service.

Transitional care management can help providers be reimbursed for transitioning their patients from an inpatient hospital setting to a community setting, such as a home, rest home, or assisted living. The included services are communications, medical decision-making, and a face-to-face audiovisual visit. The time from discharge to a face-to-face remote visit, as well as the level of medical decision-making determine the code. 99495 is used for medical decision-making of moderate complexity and a face-to-face visit within 14 days of discharge. And 99496 is used for high medical decision-making and a face-to-face visit within seven days of discharge.

Since these codes are based on medical decision-making, you will be required to utilize either the 2020 or 2021 MDM guidelines and apply them appropriately based on the medical record documentation. Let's wrap things up with a compliant billing checklist for billing and coding. Ensure that audiovisual platforms or telephone communications are clearly documented and compliant for the payer and codes that you are billing. I have heard speculation that CMS is expected to send questionnaires to Medicare beneficiaries to see how the visit was performed. Up coding is always a compliance concern. E and M visits are one of the most over coded and under documented services. The new guidelines will only add fuel to the audit fire.

Ensure that your levels are appropriately documented by the correct year of guidelines. If you haven't had a coding and documentation review of your E and M services using the 2021 guidelines, this is the time to add to your compliance and prevent audit risk. Using a non HIPAA compliant telehealth platform, if or when waivers are no longer in effect can be problematic. During the current PHE, payers permit providers to use non-compliant communication products. However, these are likely temporary leniencies. If you don't currently have one, we recommend you start looking for a HIPAA compliant telehealth solution now.

Be aware of and follow state licensure requirements for telehealth. During the current PHE, some but not all states relaxed their licensure and scope of practice rules. Know the rules and the effective dates of any waivers. Verify the documentation supports all the codes billed. For CPT, HCPCS, and ICD-10, read the CPT guidelines and ensure that all elements, such as time, are documented. Authenticate patient identity. Providers could unknowingly contribute to identity theft if they don't verify the patient identity before the services are rendered.

One way to ensure compliance is to require patients to provide a picture of their ID when scheduling the telehealth visit online, or ask patients to show their ID during the visit and document this in the note. On behalf of Bert and me, I would like to thank all of the attendees for your time today, and thank EisnerAmper for hosting us again. Back to you, Lexi.

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