Bill Dacey, MBA, MHA, CPC, CPC-I

I know that Medicare allows us to bill Audio/video Telehealth visits based only on time or decision-making, even for new patients. But what about the commercial payers that don’t – is there a way to meet the exam criteria for them via Telehealth?

 We can’t speak for any given payer, you would need to ask them their individual requirements. But we have seen the emergence of ‘Remote Examinations’ emerging from the realm of Telemedicine and now Telehealth.

One we have seen that is quite close to the standard exam that we often see for primary care was developed by 

University of South Florida – Morton Plant Mease Family Medicine

 Residency in Clearwater FL for their telemedicine curriculum, and then recently shared with hundreds of family physicians throughout Florida as part of the Florida Academy of Family Physicians COVID-19 telemedicine webinar.

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In addition to the exam itself, there is guidance for conducting the exam as follows: 

Make sure there is adequate lighting in the room, avoid backlighting

Have patient assist with exam, or someone else in the room

Ask patient to measure health data such as:

What to Document for a Telemedicine physical exam

VITALS: Pt reports temp of _ degrees F orally. Home BP today _. 

Weight measured at home: _. Blood sugar measured at home: _. 

GENERAL: Stable appearing, in no distress. Alert and oriented. 

SKIN: no visible facial rash or concerning facial lesions noted. No skin redness or discoloration seen. Patient denies seeing new skin findings on brief self-exam of arms, legs, chest, and abdomen.

EYES: conjunctiva clear, sclera non-icteric, no eye drainage, grossly normal EOM.

EARS: hearing grossly intact, no pain elicited with ear tugging bilaterally

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MOUTH: no visible perioral lesions, no perioral cyanosis, no lip swelling.

NECK: Grossly normal ROM, no visible thyroid enlargement. Patient did not palpate any cervical LAD under physician-guided exam.

HEART: Patient self-reported heart rate of _ beats per minute (

measured by patient with physician instruction, or by fitness tracker HR monitor

LUNGS: Does not appear dyspneic. No audible wheezes or rales. No nasal flaring.

ABDOMEN: no tenderness with patient self-palpation diffusely around abdomen under physician guidance, no pain elicited with jumping or leg lifts

MUSCULOSKELETAL: No significant cervical kyphosis, grossly normal active ROM in upper extremities.

NEURO: Intact recent memory. No facial or eyelid drooping. No speech impairment, answering questions appropriately.

PSYCH: Judgment and insight good; normal mood and affect.

As above, we cannot speak to the endorsement of any payers in this regard, but from the perspective of the Federal Documentation Guidelines this approach would more than cover the required components of a comprehensive physical exam.  We have not seen any suggestions from Medicare in this regard.

Continue to page 2 for the second question...

 There seems to have been some confusion about whether Medicare will cover AWV codes G0438 and G0439 via Telehealth during the Public Health Emergency (PHE).  

 We certainly understand any confusion given the oft-changing guidance from CMS on what is and what isn’t considered Telehealth, how various services are reported and also how they are paid.

The AWV codes remain on the list of covered Telehealth services for the audio/video visits. But as of the 

 call CMS also indicated that these services are also covered via audio-only connections. 

, MHA, MBA, CPC-I is principal in The Dacey Group, Inc., a consulting firm dedicated to coding, documentation and compliance concerns for physicians. Bill is an evaluation and management (E/M) coding expert and has been active in physician training for more than 25 years. He can be reached at 

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A generalized checklist for your planning. 

Coding Q&A: Remote examinations

  With the Coronavirus Emergency, what are our coding options for ‘seeing’ patients remotely

? It looks like Medicare has opened up the Telehealth or Telemedicine options?

:  There are numerous options when it comes to reporting visits that are not the traditional face-to-face office visit. This varies somewhat by payer, of course.

As you mention, on 3-17-20 Medicare has temporarily relaxed some of the geographic and security/privacy restrictions on Telehealth visits – including the office visit codes. This will allow patients to call your office, and as long as there is some type of combined audio/video communication between the provider and the patient – these ‘visits’ can be billed with the 99201-99215 series codes, adding the 95 modifier.

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 – The new visit codes to the extent the 1135 waiver requires an established relationship, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency

Any new visit codes 99201-99205 would likely need to be coded based on time given the limitations of the exam. The established patient codes 99211-99215 could be billed by counseling time or by documenting the level of history and medical decision-making associated with a given code level. 

2. Virtual Check-Ins (e.g. telephone calls) The G2012

 - A brief (5-10 minutes) check in with your practitioner via telephone or other telecommunications devise to decide whether an office visit or other service is needed. This is provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment

 - Online digital E&M service, for an established patient, for up to 7 days, cumulative time during the 7 days. For Medicare these are

-G2061 – for up to 7 days, cumulative time during the 7 days; 5-10 mins.

-G2062 – for up to 7 days, cumulative time during the 7 days; 11-20 mins.

-G2063 – for up to seven days, cumulative time during the 7 days; 21 or more minutes.  

For commercial/payers and some Medicare Replacement plans:

Those are the mainstream codes to consider here. Reimbursement varies with the office visit codes typically paying the most.

Although we cannot speak broadly for all payers, many have allowed, at least temporarily, the use of the office visit codes for Telehealth during the COVID-19 Emergency.

Some states, starting with Massachusetts, have mandated that commercial payers cover Telehealth during the crisis.

Go the websites for United Healthcare, BCBS, Aetna, CIGNA, Humana and others for specific policy changes. 

To document your visit, be sure to note in your EMR the date, time and duration of the encounter. Also record the relevant history, and exam, decision-making and other management elements as you would any other visit.

For Diagnosis coding consider the following:

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Exposure to person with confirmed COVID-19

Acute respiratory distress syndrome (ARDS)

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Medicare notified our group that effective 1/1/2020 they would no longer going to pay for the G0444 (depression screening) and G0443 (alcohol screening) to be performed together at the same visit. They will still pay for the two screenings but only if they are done at separate visits. Why would Medicare do this when these are clearly measures they want providers to perform?

:  Each Medicare contractor can make certain coverage modifications. We can’t say specifically what caused them to do that. And they don't always explain themselves. There do not appear to be  NCDs, LCDs and or Contractor articles on this.

That said, there have been comments made about these codes in general that might apply. See if these make sense. 

"In recent years, the CMS has expanded Medicare coverage of preventive services. These services (and their corresponding Medicare billing codes) include:

Annual alcohol misuse screening, 15 minutes (G0442)

Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes (G0443)

Annual depression screening, 15 minutes (G0444)
		 

Unfortunately, Medicare contractors have determined that insufficient documentation is causing many improper payments for these services. “Insufficient documentation” in this context means that something was missing from the medical records, such as:

No record of the amount of time spent providing a timed service

No physician’s signature on the medical record

To avoid these potential problems, CMS advises physicians to:

Record start and stop times, or the total time spent, when providing a timed service

Sign entries in medical records at the time of service
		 

It could easily be one of these concerns, perhaps in relation to audited claims, or something else entirely.

digital E/M services when patients email us through the patient portal,  CPT codes 99421, 99422 and 99423. Do you know if patients will incur cost-sharing if we use these codes? 

: Yes, traditional Medicare patients would have a minor co-pay. In the area of $3 for the lowest code depending where you are located. We do get a lot of questions from providers that are ok with taking the payment for their work if it comes only from a third-party payer, but that don't want to deal with patient complaints about co-pays. 

Forward looking practices are doing this, but it requires some organization. Some larger groups have not made these codes available to their providers in part because there is some potential for abuse with these. 

Since these are timed codes, there needs to be some documentation of the time spent. And there needs to be a way to make sure a record of these interactions is saved. When deploying a ‘service line’ of this sort make sure that your providers have some guidance, guardrails and mindful monitoring.

And to that end-make sure the patient understands what is involved as well. Before you'd initiate these types of services with your patients, you'd be well off to give them a heads up about any co-pays, which of course are payer specific. And probably a sales pitch on what a great time and energy saver it is versus an office visit. Remind them that this is MD time, that's what's being billed and paid for here.

There are three codes for providers that cannot bill directly–codes 98970-98972. Look into those as well if they fit your group.

Why has Medicare separated depression and alcohol screenings, and will patients incur cost-sharing with new patient portal E&M codes?

Q&A: Medicare screening changes and new E/M service codes

Our office is billing the Chronic Care management code 99490 each month for some of our sicker patients, but I want to make sure we’re doing it right

:  The 99490 is designed to capture clinical staff time of at least 20 minutes in a calendar month that is devoted to the activities associated with chronic care management (CCM).

So first you need to be certain that the basic criteria are met: The two more chronic conditions that place the patient at risk are the care plan ‘established, implemented, revised or monitored’ and the qualifying activity of staff.

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Once that is determined, it’s about leaving a footprint in the medical record that outlines the CCM-related activity. What you need to make very obvious is the total time spent, the month, the identity (including credential) of the clinical staff involved-and just what specific CCM activities were performed/addressed.

Best practice is to have the CCM patient information in a ‘plan’ document. At the top of that document make a template that allows for monthly contact info, time, date, etc.

Below that, list the various named activities 

eg. 1. Is patient Self-Monitoring?, blood sugar readings:  

Assessment/support for treatment regimen adherence and medication management

Ongoing review of patient status, including review of lab and other studies not reported as part of an EM service

Patient and/or family caregiver education to support self-management, 

Communication with Home Health/other agency, 

Facilitating access to care and services, 

These are very clearly listed in the CPT manual in the subsection text just before code 99490. You don’t have to do all these things every month-these are just general categories of things you might do. If you have something in that section one month, add it. It might not happen again next month. 

 identifying the interim Chronic Problem related activity that month. 

Often we see a plan written a year ago, copied endlessly, with a scrawled signature – and it gives absolutely no idea who did what – and what is going on with the chronic conditions.

So CCM codes aren’t for every time a patient calls for a refill, or needs a parking pass-it’s about supporting the management of specific chronic conditions. And don’t forget that CMS expects that there is real physician time directing or coordinating these staff activities… so this is meaningful, clinically necessary and relevant activity. Make sure it’s easy to see.

Continue to page 2 for the next question...

When billing consults, does the provider have to indicate in the medical record that they “CC” the referring provider.

Is there anything in writing for this? I have searched google and cannot find anything to give to the providers. We are getting denials from payers after medical records are reviewed.

: The consult requirement isn't just a CC. Look in your CPT book-that's where the generally recognized consult requirements are. Aside from a documented request for the consults, the 'consultant's opinion… must also be documented… and communicated by written report'. And they mean back to whatever source requested the consult.]

This language is really from the days of typing a letter, licking a stamp, and mailing it-it’s a little out-of-date. In settings where the medical record is shared between the requesting and consulting physicians you don’t need a separate report. This would include inpatient notes or large physician group practices  where the request for  and result of the consult is documented in the same EMR. 

That said, it just doesn’t hurt to document that the ‘results have been made available to the requesting provider’ (better with a name). That’s all the 'cc' was-an indication that something was shared. 

Documents required for Chronic Care management code 99490 and fulfilling the consult requirement.

Author | Bill Dacey, MBA, MHA, CPC, CPC-I

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Coding Q&A: Remote examinations

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Q&A: Chronic Care management and consult requirements