Telehealth Coding Update: What Practices Need To Know

COVID-19 accelerated the acceptance of telehealth services by both patients and providers for urgent and primary care and behavioral health. According to new data from FAIR Health's Monthly Telehealth Regional Tracker, national telehealth claim lines increased 3,060% from October 2019 to October 2020. That’s an increase from 0.18% of medical claim lines in October 2019 to 5.61% a year later. Based on market demands and increased implementation, it is safe to say telehealth is here to stay.

Due to the initial declaration of the Public Health Emergency (“PHE”) – and subsequent extensions – CMS and private carriers implemented rule changes to telehealth, adding flexibility and leniency in order to make accessing telehealth easier. These included expanding some telehealth services to include new patients rather than just established patients, and offering additional places of service. Post-pandemic, providers should brace for potential rule tightening and possible aggressive auditing of telehealth.

Know the Service Types

When someone says “telehealth,” one usually envisions a two-way video chat platform for real-time medical visits. But telehealth, or telemedicine, encompasses a much broader range of health care services, which providers may not have fully utilized previously. We can break services down into five major categories.

1. Audio-visual services use interactive telecommunications systems to provide health care services, with real-time audio-video technology and platforms such as Teledoc. These are the most frequently used services and include evaluation and management (“E/M”) services, where providers evaluate the patient’s condition and then manage
2. Telephone-only services, which can be a brief five-to-ten minute check-in.
3. E-visit services, which include visits by email or an online portal.
4. Asynchronous Telemedicine services, also known as “store and forward” solutions, in which a physician collects medical history, images, and various reports and then sends the information to a specialist for diagnostic and treatment expertise. Asynchronous refers to the fact that the consulting specialist, patient, and primary doctor don’t need to all be communicating at the same time, as in a phone call. Asynchronous telemedicine facilitates faster diagnosis, especially for patients located in underserved areas that may not have the necessary specialist on staff.
5. Remote Patient Monitoring services, although not technically on the telehealth code list, can be integral to chronic disease management. It allows providers to track a patient’s vital signs and other health data from a distance. If the results received are within normal ranges, they are simply recorded; if there is an abnormal finding, the physician may decide to reach out to the patient. In this category, CPT (Current Procedural Terminology) codes exist for electrocardiograms, blood pressure and glucose monitoring.

Keeping up with Telehealth Coding Changes

Changes to telehealth requirements based on the PHE made it easier for practices to offer more services to their patients, which can be delivered by additional provider types. Changes include:

• For E/M services, previously, only existing patients could be seen via telehealth; now new patients to the practice can also be seen. Also, new places of service were added including Observation Care, Initial Hospital, Emergency Department Care, Initial Nursing Facility and Home Care.
• Prior to the PHE, telephone services were limited to a few brief services. Some of these can now include both new and established patients to the practice.  One caveat is that most telehealth phone calls must not be billed with an E/M in the next 24 hours or previous seven days. Reimbursement guidelines are payor-specific, so be sure to check regulations with each payor.
• E-visit codes are based on both the cumulative time the provider spends on the visit, and whether the provider is a physician or qualified non-physician. The PHE also added licensed clinical social workers, clinical psychologists, physical and occupational therapists and speech language pathologists to the list of allowed providers for many of these services.
• Under Asynchronous Telemedicine, new patients have been added for remote evaluation of recorded video or images.
• For Remote Patient Monitoring, self-measured blood pressure was added as an allowed service during the PHE. Some services can be provided to new patients as well.

Changes to Evaluation and Management (E/M) Coding

With the E/M coding changes that became effective January 1, it will be critical for providers to understand how the E/M coding guidelines apply to telehealth. These changes require physicians to choose between medical decision making (“MDM”) or time, and guidelines have changed considerably. In addition, the requirement of time being used only for counseling or coordination of care no longer exists, which may be a boon to telehealth documentation. (Read more about changes to 2021 E/M guidelines here.)

Lastly, there are payor-specific changes regarding places of service. These vary by carrier, but CMS and most other payors direct physicians to use the place of service that would have been used if the service had been provided in person.

Documentation Rules the Day

Carrier audits are already taking place on telehealth services and many carriers have retracted payments based on insufficient documentation. It is paramount to have the documentation to support the codes billed. Telehealth has always been considered a potential area for billing fraud and abuse. In October 2020, Healthcare Finance reported that the Department of Justice charged 345 people, including doctors, nurses and other medical professionals, across 51 federal districts in what the agency is calling the largest health care fraud takedown in history. The cases account for more than $6 billion in losses, including more than $4.5 billion connected to telehealth claims occurring before the PHE.

As a guide, compliant documentation should include:

• Method of telehealth delivery, whether it is a secure two-way interactive video connection, and the platform used (Teledoc, DoxyMe), or a phone call.
• Provider and member location – remember that in non-PHE telehealth, the originating patient site and distant provider site are required elements of the documentation.
• List of all clinical participants, roles and actions.
• Time spent, if required by the CPT descriptor.
• Patient consent to receive services via telehealth.
• Other documentation required by the CPT code.

Successful Telehealth Coding

To protect against audit risk, providers should:

• Understand and support the documentation requirements of every CPT, HCPCS and ICD-10 billed.
• Conduct appropriate training for providers and revenue cycle staff, including routine updates on the changing environment.

If providers haven’t had a coding and documentation review of their E/M services using 2021 guidelines, this is the time to add it to their compliance to-do list and prevent audit risk.