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Coding for patient care outside the office


How to meet patients wherever they are-and ensure you can get paid for telehealth and virtual check-ins.

Virtual visits are on the rise.

However, despite the growing use of and demand for telehealth, experts say physicians still struggle to be adequately compensated for their services.

The Centers for Medicare & Medicaid Services (CMS) is addressing that concern by offering better reimbursement rates for telemedicine in its proposed 2019 Physician Fee Schedule (PFS). Yet physicians say getting reimbursed for virtual visits and digitally-enabled patient care remains a top challenge.

These reimbursement challenges stem, in part, from issues with medical coding: whether there’s a recognized alphanumeric code associated with a particular telehealth service; and if there is, whether a payer will accept it; and if there’s not, whether an alternative option for payment is available to the physician.

“There are all sorts of technology opportunities to interact in a non-face-to-face manner, but the payment and coding system has not kept up with that,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians (AAFP).

Technological advances over the past decade have created new ways of treating patients over the phone and via video outside of the traditional in-office visit. Patients also want to connect with their physicians via email and text and through patient portals. And some patients want to digitally share medical data, such as readings from their own personal medical devices, for evaluation.

But physicians aren’t always compensated for these visits. Medicare, Medicaid, and private payers vary in what virtual services they’ll cover. Medicare only pays for virtual visits where the physician and patient connect together in real time (synchronous visits).

, on the other hand, will pay in some states for visits where the physician and patient do not interact together at the same time (asynchronous visits), such as a patient sending a photo of a concerning rash that the physician later reviews and then prescribes a course of treatment.

As a result, physicians must educate themselves on how to code for telehealth to ensure the fiscal viability of their practices as medicine moves further into the Digital Age.

“If you don’t have a code, it’s harder to get paid-and it’s harder for the insurance company to know how to process the bill,” Moore explains.


Variants in coding sets add complexity

Most physicians already realize there are various medical coding sets with the American Medical Association’s Current Procedure Terminology (CPT) codes being the most prevalent. CMS uses CPT codes, too, but also uses Healthcare Common Procedure Coding System (HCPCS) codes to reimburse physicians for Medicare services.

But beyond the different code sets, there can be different codes for same procedures performed in the physician’s office and in outpatient settings. In other words, the code essentially describes not only what services were provided but where they were provided.

Experts say physicians should realize that using the appropriate codes isn’t always a guarantee to be reimbursed, however.

“There have been codes for telemedicine for years, but just because there’s a code doesn’t mean a health plan will pay. Coverage varies,” says Robert Tennant, director of health IT policy for the Medical Group Management Association (MGMA), headquartered in Englewood, Colo.

And that coverage can vary dramatically among payers, he and others note.

The nonprofit Center for Connected Health Policy (CCHP), which aims to increase the availability of telehealth services, explains in its 2018 report

that, “Telehealth restrictions in the Medicare program include limitations on where telehealth services may take place, both geographically and facility-wise, the limited number of providers who may bill for services delivered via telehealth, a limited list of services that can be billed, and restricting, for the most part, to only allowing live video to be reimbursed.”

The CCHP says that although state Medicaid policies “have been more progressive, each state dictates what their policies are, which creates a patchwork quilt of telehealth laws and regulations across the nation.”

Beverly Gibson, MBA, CPC-I, a senior industry adviser at MGMA, says there are codes that should be used in certain cases, along with the restrictions on them. For example, she says telephone services and online medical evaluation (non-face-to-face services) codes are 99441 – 99444; however, she notes that the codes for these services when performed by a nonphysician are 98966 – 98969.

Steps to take

To better understand coding for telehealth, experts say physicians should:

Review payer agreements.

Practices should review the agreements they have with their patients’ payers, particularly the ones they bill most frequently, to understand what specific virtual services will be covered under what circumstances, what conditions must be documented for reimbursement, and how the payer wants those services coded. “The physician should also ask whether phone calls are separately reimbursable services or not, and the same with online FaceTime-type visits,” Moore says. If they are reimbursable, practices should understand what conditions must apply.

Clarify telehealth charges.

Confirm with payers that won’t cover telehealth services whether physicians can charge patients directly for specific virtual visits or if payers consider such visits as part of a bundled service they’re already covering. “The key takeaway is to make sure you know what your contract says, how the payers view the services, and whether you can collect from the patient if [payers are] not going to pay for certain services,” Moore says.


Align with reimbursement.

Consider how to implement and offer telehealth services based on reimbursement. Tennant notes physicians can offer virtual services in a few different ways. They can implement technology to enable secure online visits or to enable secure text exchanges. Or they can work with established telehealth companies that provide telehealth services but brand their services as part of the physicians’ own practice. Tennant says these companies are generally well-versed in coding for telehealth.


Stay abreast of changes.

Regularly revisit what Medicare, Medicaid, and private payers are covering for telehealth on a regular basis. “The rules of the road can shift, which is why it’s important for the practice staff to keep up on top of these changes,” Tennant adds.


Tennant says physicians who can integrate telehealth services into their overall practices and master medical coding for such services will be most successful moving forward. “Ultimately, this is all coming down to reimbursements,” he says. “It doesn’t matter how great the technology is. If practices aren’t being paid for the services, they can’t afford to do it.”


CMS looks to expand telehealth coverage

CMS has defined rules around what it considers telehealth and what virtual services it will pay for. However, proposed new rules could expand Medicare telehealth options.

As it stands, federal law defines Medicare telehealth services as exactly equivalent substitutes for in-person services, CMS spokeswoman Maria LoPiccolo said in an email to Physicians Practice. The law currently restricts Medicare payment for telehealth services under certain conditions. Under Medicare, virtual services that are not paid for through Medicare telehealth policies are considered part of other bundled services, such as evaluation and management visits.

However, CMS’s proposed 2019 rule for the Medicare Quality Payment Program (QPP) includes changes to the Physician Fee Schedule (PFS) that will expand telehealth coverage.

“CMS is seeking to recognize changes in healthcare practice that incorporate innovation and technology to manage patient care,” LoPiccolo said. “We aim to modernize Medicare and increase beneficiaries’ access to physician services that are routinely furnished via communications technology.”

Among other provisions in the pending 2019 PFS/QPP proposed rule, CMS seeks to:

  • Pay clinicians for virtual check-ins, defined as brief, non-face-to-face assessments via communications technology such as phone or video chat.
  • Pay Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) for communication technology-based services and remote evaluation services furnished by an RHC or FQHC practitioner when there is no associated billable visit.
  • Pay clinicians for evaluation of patient-submitted photos or recorded video, such as those texted to a clinician.
  • Expand Medicare-covered telehealth services to include prolonged preventive services and longer visits for complex patients.

CMS expects to release the final rule in November 2018 that will take effect Jan. 1, 2019.

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