COVID 19: Telemedicine Resources & Guidance for U.S. Physicians

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Morgan P. Lorio, MD, FACS, Chair – ISASS Coding & Reimbursement Task Force

COVID 19: Telemedicine Resources & Guidance for U.S. Physicians

During this time of global crisis, we must work together to beat this horrible infectious disease known as COVID-19. Humans are resilient and will persevere, but our global efforts to beat this virus and apply what we learn to future practice will ultimately determine our success. Many health care providers have already made the switch to telemedicine for patient visits, and ISASS urges its members to use telemedicine with as many patients as possible to limit traffic flow—and thus potential exposure to COVID-19—in your office.

To support its members, ISASS has compiled resources on telemedicine, its requirements, and billing and coding information. However, the COVID-19 situation is rapidly changing, and it is likely that rules will be updated frequently as problems are identified. ISASS will do its best to keep you abreast of other major changes.

In the United States, under the 1135 waiver authority and the Coronavirus Preparedness and Response Supplemental Appropriations Act, the Centers for Medicare and Medicaid Services (CMS) increased access to Medicare telemedicine. Based on this waiver, Medicare can now pay for office, hospital, and other visits furnished via telehealth. Prior to the waiver, telehealth was only paid on a limited basis. Multiple types of virtual services exist, including telehealth visits, virtual check-ins, and e-visits. Although Medicare requires live video (you and the patient need to be able to see each other live) while performing a telemedicine visit, many insurance carriers are waiving this requirement, and some states have ordered private carriers to waive this requirement.

Medicare has said it will not pursue violations to the Health Insurance Portability and Accountability Act (HIPAA) related to the use of telemedicine during this time of crisis. Therefore, providers can use other forms of video communication, such as FaceTime and Skype. Medicare is under considerable pressure to further relax the rules requiring live video as well, especially because so many seniors have trouble with video technology. Because seniors are the most vulnerable population, CMS will want these patients to stay at home. We will continue to provide updates as Medicare rules evolve.

Most carriers (including Medicare) are allowing evaluations of both existing patients (99211-99215) as well as new patients (99201-99205) via telemedicine with a place of service as the physician’s office (typically -11). If you conduct the visit by live video, bill the normal evaluation and management (E/M) code as if it’s in the office with a -11 place of service and a -95 modifier to indicate use of telemedicine. Medicare and most major carriers have said they will reimburse these services at 100% of the normal visit. Also note that some carriers have said they will waive patient co-pays for these telemedicine visits.

If the visit is purely telephonic, Medicare is requiring a different set of codes (99441-3). Site of service for most carriers (including Medicare) is -02 for these codes, but a few private carriers have different coding requirements. Additionally, workers compensation rules will vary state to state, and you will need to contact your workers compensation commission to ask how telemedicine is being handled. At this time, it is our understanding that most workers compensation packages are covering telemedicine.

The requirements for documentation are the same as if you did the service and billed that code in the office. Time or clinical documentation that follows the 1995/1997 CMS documentation guideline definition of the three key components of an E/M visit (patient history, patient examination, and complexity of medical decision making) is required to justify a specific code. In most instances, you will be achieving your coding level by your documentation and not time; thus, carefully document your visit with the patient. For example, a level three (99213) established patient office visit can be billed if you spend 15 to 25 minutes with the patient and/or family member or documentation establishing at least two of the three components of medical decision making (an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity) for a presenting problem of low to moderate complexity. Lower level visits like a 99212 require less time (10-15 minutes) and/or a low complexity presenting problem, whereas higher level visits like a 99214 require more time (25-40 minutes) and/or a higher level of complexity presenting problem. Include time spent counseling regarding COVID-19 infections, which you should be doing with all patients, as many patients are still naïve as to how serious COVID-19 really is.

Another key issue facing physicians in the COVID-19 pandemic is the increased liability risk. Both at the federal and state levels, liability waivers related to COVID-19 impact physician liability exposure.

The resources provided below include links to CMS updates for Medicare along with guidance from the American Medical Association (AMA) on correct current procedural terminology (CPT) coding and documentation. We also have provided links and updates from several private carriers, but these may or may not apply to your specific locale. We strongly advise that members check this information with their local private carriers. As you learn what each of your carriers are doing, please disseminate that information among your colleagues within your state—we are all in this together.

 

Medical Liability and Malpractice Resources and References
Telemedicine and Telehealth Resources and References

Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency
In light of the COVID-19 nationwide public health emergency, the HHS Office for Civil Rights (OCR) is exercising its enforcement discretion and, effective immediately, will not impose penalties on physicians using telehealth in the event of noncompliance with the regulatory requirements under the Health Insurance Portability and Accountability Act (HIPAA). Click here for more information about the specific requirements.

AMA Telehealth Resources
        • AMA Physician’s Guide to COVID-19. This quick-start COVID-19 physician guide, curated from comprehensive CDC, JAMA Network, and WHO resources, will help you prepare your practice, address patient concerns, and answer your most pressing questions.
        • Quick Guide to Telemedicine in Practice. This new resource will help you mobilize remote care with implementation tips, as well as a reference to CPT codes for reporting telemedicine and remote care services.
        • STEPS Forward. This educational module contains information on initiating the use of telemedicine in practice.
        • Digital Health Implementation Playbook. This resources provides a 12-step process for adopting remote monitoring of patients outside the traditional clinical environment.
CMS Telehealth Resources
Private Payor Telemedicine Policies
Aetna

o    Aetna Medicare Advantage/Commercial

Reimbursement is 100% of a face-to-face visit for the allowed codes

Anthem/Blue Cross Blue Shield

o    Anthem Commercial Reimbursement Policy

o    Anthem updates regarding COVID-19 and telehealth

Commercial reimbursement is 77.25% of a face-to-face visit for the allowed codes. On and off exchange reimbursement is 73.03% of a face-to-face visit for the allowed codes. Medicare Advantage Reimbursement is 100% of Medicare.

Cigna

o    Cigna COVID-19 Interim Billing Guidance for Providers

Telehealth with or without video for COVID-19 – Cigna will reimburse for code G2012. Telehealth with or without video for NON-COVID-19 – Cigna will reimburse for CPT code 99241 with Place of Service 11 (ICP has confirmed coding with Cigna).

United/Oxford

o    United/Oxford updated policy (including Medicare Advantage)

United/Oxford commercial reimbursement is 100% of a face-to-face visit for the allowed codes.

Additional Resources and Information
Regulatory Changes
Reimbursement and Financial Relief