Telehealth & Telephone Examinations – Best Practices ...



Please note that the information contained in this document may be privileged and confidential. This document is designed for Hoag’s Community Physicians to assist in providing answers to many of the common Telehealth questions arising from the changing environment in Healthcare operations, due to COVID-19. This information is rapidly evolving as individual Payers and Health Plans determine specific guidelines around the various areas related to patient communication, clinical evaluation, coding requirements, claims processing, provider credentialing, etc. based on the original CMS 1135 Waiver. However, this FAQ may serve as a baseline document into Hoag’s physician practices to provide information surrounding the CMS waiver and operational considerations for our clients to maintain optimal outcomes, during a rapidly changing patient experience landscape, due to COVID-19.Telehealth & Telephone Examinations – Best Practices, Guidelines, and FAQsBased on Communication from DMHC under the declaration of the COVID-19 Public Health EmergencyAll payorsTelehealth (2-way Video and Zoom) & Telephone VisitsCPTwRVUIf E&M components of service and appropriate documentation New Patient^99201-99205Same as In-Office VisitEstablished Patient99212-99215For Established Patients Only, if the discussion does not meet the E&M documentation guidelines5-10 min of medical discussion99441*0.2511-20 min of medical discussion99442*0.5021-30 min of medical discussion99443*0.75* These CPTs codes should not be used before or after office visit if originating from a related E&M service provided within the previous 7 days nor leading an E&M service within the next 24 hours or soonest available appointment. HCC Coding: Telehealth and NOT Telephone visits meet requirements for risk adjustment via face to face examinationNew Patients Medicare“It is imperative during this public health emergency that patients avoid travel…to physicians’ offices, clinics…HHS is announcing a policy of enforcement discretion to the extent the waiver section 1135 requires that the patient have a prior established relationship with a particular practitioner, HHS will not conduct audits to ensure that such a prior relationship existed …during this public health emergency.”Telehealth Services Coding GuidelinesPatients must be established under the practice (at least one visit in the last 3 years)Call must be personally performed and documented in the medical record by the providerEncounter must be patient-initiated via phone call or by general consentInformation discussed cannot be directly related to a prior visit (within the last seven days)Patient will NOT be seen in-person during the next 24 hoursVerbal Consent Verbiage should be in the note (see below)Physicians must obtain verbal consent and include the following Telehealth Verbal Consent Verbiage in the note. Hoag recommends the following verbiage: Telemedicine enables health care providers at different locations to provide safe, effective, and convenient care through technology. As with any health care service, there are risks associated with telemedicine, including equipment failure, poor images, and information security issues. You have the right to withhold or withdraw your consent to use Telemedicine at any time. Patient verbally consented to the use of telemedicine in their medical care. Note: Some EHRs have the capability to add common text and phrase short keys, consider adding a short key to automate the process for adding this verbiage. Patient LiabilityHoag is following these practices:Waiving copays for all original Medicare (Fee For Service) beneficiaries until the public health emergency endsWaiving copays for HMO/PPO plans except for Self-Insured Plans with:ICD10 diagnosis codes specific to coronavirus and COVID-19 illness (Z03.818 or Z20.828)Hoag recommends that independent providers contact Health Plans and delegated entities before following these practices.As Diagnosis may not be captured at the time of payment collection, patients should be informed that they may be liable and billed for coinsurance. If a member’s plan ID card indicates “Administrative Services Only,” the member’s plan is under a self-funded client. Self-funded plans are governed by the Employee Retirement Income Security Act of 1974 (ERISA), which is federal law. Self-funded plan sponsors?may opt-out of compliance with the state mandate to waive cost-sharing for COVID-19 screening and testing. For these plans, Hoag is collecting copay regardless of symptoms. Hoag is collecting Health Plan specific information, please reach out to Hoag Physician Partners (HPP.Providers@) for more information. Providing Clinical Summaries (After Visit Summaries)The after visit summary (AVS) is given to patients after medical appointments to summarize their health and guide future care. If properly designed, the AVS can be an educational tool to facilitate patients’ understanding of their health, reduce recall problems, and encourage adherence to self-management tasks. Hoag suggests practices leverage their Patient Portal to securely send Clinical Summaries to its patients for examinations performed via Telehealth.FAQsQ. Can I use FaceTime instead of Zoom?Under the Telehealth 1135 Waiver, the use of telephones which have audio and video capabilities for delivering Telehealth services have been authorized for us, during the COVID-19 PHE. Additionally, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against healthcare providers who serve patients in good faith via everyday communications technologies, such as Facetime or Skype, during the COVID-19 PHE. For those interested in using video conferencing, Hoag encourages the use of Zoom’s HIPAA compliant platform (). Please also note that the government is currently allowing physicians to use Skype, Facebook messenger, the free version of Zoom and other HIPPA non-compliant applications. Hoag would caution the use of those platforms. Q. Do I submit a charge for a telehealth visit if I need to bring the patient in for further evaluation?CPT guidelines state you may not bill a 99441-9943 and G2012 telephone evaluation and management leading to an E&M Service or procedure within the next 24 hours or soonest available appointment. Q. Do I submit a charge for a telephone/telehealth visit if it is a follow-up telephone/telehealth visit from an earlier visit?CPT guidelines state you may not bill a 99441-9943 and G2012 telephone evaluation and management originating from a related E&M service provided within the previous 7 day.Q. Will HMO/PPO plans cover telephonic only services in addition to telehealth via video + audio?Yes, to address the concerns, the health plans have heard from providers about the need to support care to patients during extended periods of social distancing they have revised their guidelines. During this time PPO and HMO plans will cover telephone-only telehealth services when appropriate. These services are reported with the appropriate E/M codes 99201-99215 supported by provider documentation of history, exam, MDM.Exceptions include: chiropractic services, physical, occupational, and speech therapies. These services require face-to-face interaction and therefore are not appropriate for telephone-only consultations. Q. What is the reimbursement rate for telehealth and telephonic services?PPO/HMOs – due to recent changes, as required by the State of California, telehealth and telephonic services must be paid at the same rate, whether a service is provided in-person or through telehealth or telephonically, if the service is the same regardless of the modality of delivery, as determined by the provider’s description of the service on the claim.CMS has not made these changes. Telephone only visits for these payers are still reported with code G2012.Q. We have heard conflicting information about whether Telehealth Visits billed with E/M codes 99201-99205, 99212-99215 can be provided via Telephone only? Due to recent changes, all Telehealth Visits for PPO/HMO patients can be billed with E/M codes 99201-99215 when performed using two-way audio and video.Q. How can a physician or qualified health professional generate an E&M code from a telehealth examination? Telehealth exams can be challenging to generate E&M components of service and documentation. Below are some examples of what exam elements may look like:patient is speaking full sentencespatient is alert and orientedmood and behavior appropriateno signs of distressno wheezing heardaudible congestion in his voicecoughing on the phonecan move neck in all directions without painable to walk normallyable to move all extremities without weaknessno rashes, lesions If the patient has the appropriate equipment at home (i.e., Blood pressure monitor, scale, HR monitor, etc.) the physician can verify the reading/value and document this in the note under the exam.? Please note that the patient took their vitals on their own equipment, and you verified the reading/value.Also, remember established patients only require 2 of the 3 key components to be documented to bill for the level of service (99212-99215), so if your exam is minimal or unobtainable, you can base your E/M on History and Medical Decision Making.Q. Can I conduct a telehealth appointment if the parent/guardian is not physically in the same location as the patient/minor?Yes, as long as both the parent and child join with video and audio.? Per the American Telemedicine Association Operating Procedures for Pediatric Telehealth: If a parent is not physically present at the originating site, and would like to participate in the examination, the option to join may be put in place to allow the parent to participate, i.e. telephone, multipoint video, etc.Q. If I conducted a telephone (no video) visit for a PPO/HMO patient but met the elements to qualify for an E/M visit, should I bill for a Telehealth E&M service or the 99441-99443 telephone visit codes? Telephone only visits (HMO or PPO payers) would be billed with the appropriate CPT codes 99201-99215 when the required elements (History, Exam and MDM) are documented.Q. If I conducted a telephone (no video) visit for a Medicare FFS patient but met the elements to qualify for an E/M visit, should I bill for a Telehealth E&M service or with the telephone visit codes 99441-99443 or G2012? Medicare FFS telephone only visits are coded with G2012. Without 2-way audio and visual, these payers do not allow Telephone visits to be reported with CPT codes 99201-99215 or 99441-99443.Q. What codes would be appropriate to consider for a telehealth or telephonic visit?PPO/HMO Plans - telehealth or telephonic services should billed with the same CPT codes that they would normally bill for in-person visits with a modifier GT and Place of Service (POS) code “02”. If a different modifier is required due to individual plan requirements, the correction will be done on the back end.CMS has not made these changes for Medicare FFS. Telephone only visits for these payers are still reported with code G2012.Q. Can you report CPT code 99441 or G2012 for a Telephone visit that was less than 5 minutes?No, if the specified time requirement is not met, it is a non-billable service. Both CPT codes 99441 and G2012 require at least 5 minutes of medical discussion. If at least 5 minutes of medical discussion was not provided you would report the service with code 99499 - N/C visit.Q. Can Telephone Visits (CPT Codes 99441-99443) be provided to new patients? And will all payers cover these codes?No, these Telephone visit codes can only be provided to established patients.Report Telephone only visits based on time or when the key components of an E/M service are not documented in the note (history, exam, MDM) with CPT codes 99441-99443. For Medicare FFS report Telephone calls with code G2012Q. Can Telephone Evaluation and Management Visits be provided to new patients? Telephone calls and online evaluations are still for established patients only. Under normal circumstances new patient visits via Telehealth (two-way audio/visual) would not be covered by CMS or other health plans. However, due to the COVID 19 health emergency New Patient visits (CPT codes 99201-99205) may be performed and reported through telehealth NOT telephone (audio-only). Q. Does any other modifier i.e. 95, GQ need to be added for Telephone visits?Hoag’s current workflow is to add modifier GT, if a specific payer requires 95 or other modifier, Hoag will correct it on the back end. Please check with your IT and Revenue Cycle Services on your system configuration.Q. Does Place of Service need to be added for Telephone visits?Our current workflow links the Correct Place of Service (02) for telehealth or telephone within the Appointment Type. This does not need to be noted in the documentation. Please check with your IT and Revenue Cycle Services on your system configuration.Q. What if the patient calls on multiple days, can these visits be billed each day? It is important to look at the description/definition of each code. Some codes do not define limit on how many times per week a code can be billed, and some are defined as cumulative and to be coded and billed only once a week. Q. Is there a total list of telehealth approved codes?The 2020 Telehealth Approved Codes:LIST OF MEDICARE TELEHEALTH SERVICES CY 2020CodeShort Descriptor90785Psytx complex interactive90791Psych diagnostic evaluation90792Psych diag eval w/med srvcs90832Psytx pt&/family 30 minutes90833Psytx pt&/fam w/e&m 30 min90834Psytx pt&/family 45 minutes90836Psytx pt&/fam w/e&m 45 min90837Psytx pt&/family 60 minutes90838Psytx pt&/fam w/e&m 60 min90839Psytx crisis initial 60 min90840Psytx crisis ea addl 30 min90845Psychoanalysis90846Family psytx w/o patient90847Family psytx w/patient90951Esrd serv 4 visits p mo <2yr90952Esrd serv 2-3 vsts p mo <2yr90954Esrd serv 4 vsts p mo 2-1190955Esrd srv 2-3 vsts p mo 2-1190957Esrd srv 4 vsts p mo 12-1990958Esrd srv 2-3 vsts p mo 12-1990960Esrd srv 4 visits p mo 20+90961Esrd srv 2-3 vsts p mo 20+90963Esrd home pt serv p mo <2yrs90964Esrd home pt serv p mo 2-1190965Esrd home pt serv p mo 12-1990966Esrd home pt serv p mo 20+90967Esrd home pt serv p day <290968Esrd home pt serv p day 2-1190969Esrd home pt serv p day 12-1990970Esrd home pt serv p day 20+96116Neurobehavioral status exam96150Assess hlth/behave init96151Assess hlth/behave subseq96152Intervene hlth/behave indiv96153Intervene hlth/behave group96154Interv hlth/behav fam w/pt96160Pt-focused hlth risk assmt96161Caregiver health risk assmt97802Medical nutrition indiv in97803Med nutrition indiv subseq97804Medical nutrition group99201Office/outpatient visit new99202Office/outpatient visit new99203Office/outpatient visit new99204Office/outpatient visit new99205Office/outpatient visit new99211Office/outpatient visit est99212Office/outpatient visit est99213Office/outpatient visit est99214Office/outpatient visit est99215Office/outpatient visit est99231Subsequent hospital care99232Subsequent hospital care99233Subsequent hospital care99307Nursing fac care subseq99308Nursing fac care subseq99309Nursing fac care subseq99310Nursing fac care subseq99354Prolonged service office99355Prolonged service office99356Prolonged service inpatient99357Prolonged service inpatient99406Behav chng smoking 3-10 min99407Behav chng smoking > 10 min99495Trans care mgmt 14 day disch99496Trans care mgmt 7 day disch99497Advncd care plan 30 min99498Advncd are plan addl 30 minG0108Diab manage trn per indivG0109Diab manage trn ind/groupG0270Mnt subs tx for change dxG0296Visit to determ ldct eligG0396Alcohol/subs interv 15-30mnG0397Alcohol/subs interv >30 minG0406Inpt/tele follow up 15G0407Inpt/tele follow up 25G0408Inpt/tele follow up 35G0420Ed svc ckd ind per sessionG0421Ed svc ckd grp per sessionG0425Inpt/ed teleconsult30G0426Inpt/ed teleconsult50G0427Inpt/ed teleconsult70G0436Tobacco-use counsel 3-10 minG0437Tobacco-use counsel>10minG0438Ppps, initial visitG0439Ppps, subseq visitG0442Annual alcohol screen 15 minG0443Brief alcohol misuse counselG0444Depression screen annualG0445High inten beh couns std 30mG0446Intens behave ther cardio dxG0447Behavior counsel obesity 15mG0459Telehealth inpt pharm mgmtG0506Comp asses care plan ccm svcG0508Crit care telehea consult 60G0509Crit care telehea consult 50G0513Prolong prev svcs, first 30mG0514Prolong prev svcs, addl 30mG2086Off base opioid tx first mG2087Off? base opioid tx, sub mG2088Off opioid tx month add 30 ................
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