• Savvy Coder

    Telemedicine During the COVID-19 Public Health Emergency

    Written By: Sue Vicchrilli, COT, OCS, OCSR, Academy Director of Coding and Reimbursement

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    On March 17, in response to the COVID-19 crisis, CMS announced that it would temporarily ease the rules on telehealth, making it feasible for patients across the country to seek health care without traveling to the physician’s office. The goal was to reduce the exposure risk for patients, for physicians and their staff, and for the community at large.

    Use the online resources. The American Academy of Ophthalmic Executives (AAOE), working closely with the Academy’s regulatory experts, has been tracking how CMS is implementing the new rules. They have been keeping members up to date on this with a robust series of webinars, tip sheets, articles, and discussions on the AAOE’s eTalk listserv (aao.org/practice-management/listserv).

    Bookmark this URL. Government regulations can change quickly. For the latest information on telehealth reim­bursement, see the AAOE web page, “Coding for Phone Calls, Internet, and Tele Health Consultations.”

    What questions has the AAOE been fielding? Here is a small sample of fre­quently asked questions (FAQs).

    Telemedicine FAQs

    Note: If you are billing a commercial payer, make sure you check the individ­ual payer’s policies.

    Q. How long will physicians be able to bill using the new flexibilities of telehealth?

    A. The telehealth waivers will be effective until the Secretary of Health and Human Services declares that the COVID-19 Public Health Emergency (PHE) has ended.

    Q. What about those patients who worry that they’ll be out of pocket because Medicare and other payers won’t cover telehealth?

    A. During the PHE, you should tell patients that services are available by phone, email, or virtual communication in new locations, including homes.

    Q. Some emergency visits involve the patient coming to our clinic and others are conducted virtually. How do we code for these different types of visit using the 99201-99215 family of Evaluation & Management (E/M) codes?

    A. Modifier –95 flags that a visit involved telehealth. So if the visit was done virtually, append modifier –95 to the relevant E&M code. If you don’t use that modifier, the payer will assume that the physician and patient were bothphysically in the office.

    During the PHE, what place of ser­vice (POS) code should you use? Even if the visit was conducted via telehealth, use 11 (which is the POS code for the office) when submitting CPT codes for services that would normally only be billable when you performed them in the office.

    Q. Have there been any changes to the supervision rules for testing services?

    A. Yes. Tests that had previously required direct supervision can be done under general supervision during the COVID-19 PHE.

    Q. Previously, Medicare paid for services billed by teaching physi­cians when the services have been furnished by residents, provided the residents were under direct super­vision of a teaching physician. Does that apply to telehealth?

    A. During the PHE, yes. Because physical proximity can result in unnec­essary exposure risks, CMS is allowing residents to perform services via tele­health, and it is temporarily redefining the direct supervision requirement to include virtual supervision. The teaching physician doesn’t have to be physically present. Instead, he or she can have a virtual presence “through audio/video real-time communications technology when use of such technol­ogy is indicated to reduce exposure risks for the beneficiary or health care provider.” The regulations describe this as “direct supervision by interactive telecommunications technology.”

    Q. In telemedicine, can the history be taken by phone prior to exam by a staff member and documented into the medical record?

    A. Yes. However, staff time can’t be included when you determine whether the practice can bill for a phone call, an e-visit, or a telemedicine exam.

    Q. Can you bill the Eye visit codes for exams conducted via telemedicine?

    A. Effective April 30, CMS added Eye visit codes to the list of codes that—during the PHE—are covered when conducted via telemedicine. Please note:  

    • As always, the chart documentation must cover the level of service that you bill for.
    • You can meet the level of service for the intermediate Eye visit codes (92002 and 92012) via a virtual face-to-face interaction, but the comprehensive Eye visit codes (92004 and 92014) require exam elements that can’t be done virtually.
    • For POS code, use 11 (the office code)
    • Append modifier –95, to indicate that the exam involved telehealth
    • This expansion may be unique to CMS

    To learn more about use of Eye visit codes, see “Fact Sheet for the Comprehensive Eye Visit Codes; 92004 and 92014” (April 2020, EyeNet).

    Q. We are considering going to nursing homes and assisted living facilities to do intraocular injections and are wondering about reimbursement. We know that we shouldn’t charge for an office visit and the place of service would be nursing facility or assisted living facility. Would Medicare pay for Eylea, Lucentis, or Avastin in a nursing facility, assisted living facility, or skilled nursing facility (SNF)? And can we charge a telemedicine visit, too?

    A. There are some key points to consider:

    • Is the facility in lockdown? If it is, you’ll need approval to enter.
    • What about the telemedicine exam? Even if medically necessary, and no matter the place of service, the exam is not separately billable if it was performed solely to confirm the need for the injection. The PHE doesn’t change the rules relating to use of modifier –25.
    • When you bill for the injection, make sure that you use the correct POS code. Many facilities have separate wings—one wing, for example, might be for assisted living, another might be a nursing home, and a third could be a skilled nurs­ing facility. You should therefore confirm that you are using the correct POS code.
    • In an SNF, injected medication is not a covered benefit, not even during this PHE. You would need to use a sample.
    • In assisted living or nursing homes, drugs should be payable—but to be cautious, consider using a sample. If your claim was denied, and your appeal lost, you would not be able to bill the patient out of pocket.