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  • The New Normal: Nuances of the Hybrid Telehealth/In-Person Exam

    By Joy Woodke, COE, OCS, OCSR, Academy Coding and Practice Management Executive, and Sue Vicchrilli, COT, OCS, OCSR, Academy Director of Coding and Reimbursement

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    Telemedicine options can help you to stay in contact with your patients, and—by reducing the number of in-office visits—can help expand your patient exam capacity. But not everything can be done remotely, resulting in hybrid telehealth/in-person encounters.

    The new normal. Due to social distancing requirements and patient requests, histories taken by phone and drive-up intraocular pressure (IOP) checks are the new normal for many practices. Many ophthalmology prac­tices have been offering telemedicine appointments for some conditions, and are combining these with in-person testing services.

    Tips for the Hybrid Exam

    When utilizing telemedicine hybrid encounters, keep the following issues in mind.

    Protocol driven. Physicians should direct the scheduling of telemedicine hybrid encounters based on patient-specific criteria or a comprehensive clinical scheduling protocol.

    Physicians must request tests ahead of time. All delegated testing services still require a physician order that is documented prior to performance of the test.

    Document informed consent. Patients must verbally consent to the telemedicine encounter.

    Frequency limits. A typical hybrid telemedicine encounter may include a combination of an onsite testing service with a subsequent telemedicine exam. For example, a common scenario may involve a dry age-related macular de­generation (AMD) patient visiting the office for a fundus photo and an optical coherence tomography (OCT) screen­ing followed by a telemedicine exam­ination. When coding for these hybrid exams, remember that payers may each have their own unique policy and fre­quency limit for each test performed.

    Bundled codes. When you perform more than one test on the same day, review the Correct Coding Initiative (CCI) edits to see whether those tests are bundled together (e.g., fundus pho­to and OCT are still bundled).

    What about MIPS? In the Merit-Based Incentive Payment System (MIPS), your score for some quality measures will depend on how your performance rate compares against a benchmark. When services are provided to a patient via telemedicine, that patient might be included when calculating the performance rate of some—but not all—quality measures.

    Suppose, for example, you bill one of the E/M office visit codes (99201-99215) and you append modifier –95, which indicates that telemedicine was used. This patient encounter would be included in the performance rate if you are reporting measure 130: Documenta­tion of Current Medications in the Medi­cal Record but not if reporting measure 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention.

    How do you know whether or not telehealth encounters are included when calculating a quality measure’s performance rate? First, go to and look for the quality measure that you are interested in. Next, check the list of CPT codes that show which patient encounters are included and see if there is a caveat about telemedicine modifiers at the end of that list.

    Ethics in Telemedicine

    This April, the Academy published a new ethics Information Statement titled “Ethics in Telemedicine.”

    In addition to touching on legal considerations, it covers six ethical issues: competence, informed consent, conflict of interest, confidentiality, continuity of care, and preservation of data.

    Three Sample Scenarios

    Consider the following hybrid scenarios.

    Scenario #1: A 70-year-old woman schedules a follow-up evaluation of her dry AMD. Here’s what happens.

    • A staff member obtains her history via a phone call and documents it in the medical record.
    • Because the patient is at high risk for severe COVID-19 illness, a telemedicine hybrid appointment is offered based on the clinic’s scheduling protocol.
    • The physician reviews the chart and assesses the previous exam, visual acuity (VA), and findings.
    • A retina OCT is ordered, and this order is documented in the medical record.
    • The patient is scheduled for a VA test and OCT at the satellite office clos­est to her home.
    • A subsequent telemedicine appointment with the ophthalmologist is scheduled at the next convenient date and time.
    • At the satellite office, a technician tests VA and conducts an OCT clinic. To enhance social distancing, this is scheduled to start 30 minutes after the previous patient. There is no wait for the patient, and additional time is allot­ted for sanitation between tests.
    • During the telemedicine appoint­ment, the physician reviews the history, VA, and OCT, discusses the findings, and provides recommendations to the patient.

    Scenario #2: A 62-year-old man is recalled for a four-month glaucoma check. Here’s how a hybrid exam could take place.

    • After reviewing the patient’s chart and previous visual fields and glaucoma OCT, the physician considers telemed­icine options due to the lack of avail­ability for a timely clinic appointment.
    • The patient is scheduled for an IOP check at the next available drive-up clinic, with a follow-up telemedicine appointment with the physician.
    • The follow-up telemedicine encoun­ter is conducted. The physician reviews the IOP, discusses current medications and findings, and provides recommen­dations to the patient.

    Scenario #3: How would you code this one?

    • A patient comes into the office, and a technician checks the patient’s VA and IOP, and performs any other test(s) that the physician has ordered (e.g., fundus photography or OCT).
    • The technician performs a slit-lamp exam via a video slit-lamp system. 
    • The physician is off site and views the slit-lamp exam remotely. 
    • While the technician is in the room with the patient, the tech gets the phy­sician on video to finish the exam with discussion and treatment.

    Would this video discussion be considered a telemedicine service (since the physician is off site) or a regular nontelemedicine service (since the patient is in the office)? At time of press the Centers for Medicare & Medicaid Services (CMS) had not provided direction for this type of scenario, but it is the AAOE’s best judgment that the video discussion portion of the visit would be considered a telemedicine service. 

    A Patient Won’t Come In?

    During the current pandemic, patients are sometimes reluctant to leave home and enter physician offices, ambulatory surgery centers, and hospitals—even for visits and procedures that they need and want.  

    Data from multiple large health care systems demonstrate that a personal call from the physician is far more valuable and effective than a call from staff in helping a patient return for care. This appears to be particularly true if the physician takes a few min­utes to speak about the steps that are being taken to keep patients and staff safe—and to articulate the need for continued care or surgery.  

    The bottom line: Nothing appears to be more effective than the personal relationship between patient and phy­sician.


    FURTHER READING. For answers to some FAQs, see “Telemedicine During the COVID-19 Public Health Emergency” (June 2020, EyeNet). For further infor­mation on telemedicine coding, visit