The time is now to get acquainted with the new guidelines.
A New Horizon for Emergency Physicians:
The application of telehealth services in Emergency Medicine always seemed like an intriguing idea. It just was never practical…until now. With the arrival of COVID-19, a number of sweeping policy developments have come into play that have transformed this service from a passing thought into a thriving reality.
Multiple restrictions have been waived that have greatly improved access to telemedicine for both patients and providers. Just earlier this year, before the COVID-19 pandemic turned our healthcare system sideways, telemedicine services were primarily restricted to established patients only. Furthermore, patients were prohibited from receiving this service in their home.
Additionally, geographic restrictions limited availability to those regions with a shortage of healthcare providers. With the United States’ efforts to combat Coronavirus, all that has changed.
Here Are the Positives for All:
A number of advances have created a favorable platform where telehealth services can now flourish. Established patient, originating site and geographic restrictions have all been waived by CMS during this time of “Public Health Emergency.”[1] This means any patient seeking care can receive telehealth services from their home. Similarly, a physician can provide telehealth from their office, hospital and even home as well.
Another tailored policy shift is Drug Enforcement Agency guidelines now allow DEA-registered clinicians to issue prescriptions for controlled substances via telehealth services. Previously, these were restricted to in-person medical evaluations. All of these transformations have made telehealth a realistic care-delivery vehicle in the battle against coronavirus.
Another reason for the Emergency Medicine telehealth boom — clinicians now have the financial support they need for this to become a viable practice solution. Over the past several months: 1) Congress passed the Coronavirus Supplemental Appropriations Act that authorized $500 million to improve telehealth services, and 2) The CARES Act allocated $200 million to the Federal Communications Commission to assist healthcare providers with telehealth. The “COVID-19 Telehealth Program” was brought forth as a result.
This three-year grant program will support healthcare providers who undertake endeavors for low-income or veteran patients. All of these funding opportunities have allowed Emergency Medicine groups to develop the infra-structure needed to effectively deliver telehealth.
The telehealth reimbursement structure for emergency physicians has undergone dramatic upgrades as well. During this public health emergency, telehealth services now include ED Visit codes (CPT 99281-99285), Critical Care codes (CPT 99291-99292) and Observation Service codes.[2]
Given the limitations for patient access with this pandemic, billing is allowed by CMS at the same rate as if the service had been furnished in person. Thus, Emergency Medicine Evaluation/Management services can now be provided and paid for via telehealth. As reimbursed by Medicare in 2020, Level 3 (99283), Level 4 (99284) and Level 5 (99285) encounters generate $66.40, $ 121.98, and $ 177.20 respectively.[3]
This time of Public Health Emergency for COVID-19 has already been extended by the department of Health and Human Services and will likely continue for the remainder of the year. Along similar lines, telehealth reimbursement for ED Visit services (99281-99285) may very well carry through 2020. Moreover, CMS’s Final Rule is undergoing revisions for the year ahead, and there remains a possibility that telehealth reimbursement for higher level services (including 99284-99285) could continue in 2021.
Useful Caveats That Are Good to Know:
In navigating this new expansion of telehealth, there are several important points to keep in mind. First and foremost, an audio-video “real-time” interaction between the patient and provider is required for the ED related CPT codes. While audio conversations alone don’t qualify as telehealth services for emergency medicine codes, interactions involving phones with audio-video capabilities are permissible.
Furthermore, the use of mainstream applications that offer video chats can be used to provide telehealth (examples include Apple FaceTime, Facebook Messenger video chat, Google Hangouts video and Skype).[4] Provided the service is administered in “good faith,” enforcement of HIPPA violations in telehealth have been waived. However, patient confidentiality still matters — public-facing platforms (i.e. TikTok, Facebook Live) are prohibited for use in telehealth.[5]
There are other factors to consider. Ancillary services, such as virtual check-ins and telephone visits, do not qualify under telehealth. From a provider standpoint, nurse practitioners and physician assistants are now permitted to provide telehealth services by CMS. Additionally, teaching physicians can now use telehealth to supervise the “key portion” of a resident’s service as well as supervise their diagnostic interpretations.
Finally, be aware insurance carrier rules are evolving. Not all payers are conforming to CMS guidelines. Different payers have different allowances for Place of Service codes — including the ones for telehealth vs. emergency department. Be sure to monitor your account receivables to appeal denials.
Keep in Mind The Bottom Line:
If you really want to excel in telehealth, take special note of this last point — documentation requirements for Emergency Care Telehealth encounters still remain the same. In order for you to reimburse properly, your charting will need to be complete. For patients receiving telehealth visits in their home, CPT 99284 visits require four History of Present Illness (HPI), two Review of Systems (ROS), one Past Medical, Family, Social (PMFS), and five Physical Exam (PE) elements. For patients located at facilities where ancillary tests are available, Emergency Care Telehealth visits CPT 99285 require four HPI, 10 ROS, two PMFS, and eight PE elements.
Your HPI should detail the appropriate complexity and severity of illness for a given encounter. Also, be sure to detail any chronic medical illnesses and highlight acute exacerbations with your documentation. Always include a Differential Diagnosis.
With your physical exam, 11 organ system elements can be obtained – even in telehealth. (For example, “Constitutional: well nourished, well developed; Eyes: no conjunctival injection; ENT: mild pharyngeal injection; Cardiovascular: no JVD, capillary refill less than two sec; Respiratory: no accessory muscle usage, no cough noted; Gastrointestinal: abdomen non-distended; Musculoskeletal: elbows / wrists non-swollen; Skin: no petechaie; Neurological: awake and alert, movement symmetrical UE/LE; Psychiatric: no flight of ideas; Immunologic: no hives.”) – that’s 11!
Lastly, be sure to detail any COVID-19 testing in your diagnostics, and list “COVID-19” or “Suspected COVID-19” with your diagnoses when appropriate. That’s the recipe for success in this unique time. These are the steps that will serve you and your patients best.
Peer reviewed by Jim Blakeman – physician reimbursement, medical coding, and policy development expert. He serves as Executive Vice-President at LogixHealth and also resides on EDPMA’s Quality Coding Documentation Committee. Share your interests and comments: jblakeman@logixhealth.com
References:
- CMS.gov ; “Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19” CMS.gov/files/document/covid-19-physicians-and-practitioners.pdf
- CMS.gov; “List of Telehealth Services” CMS.gov/Medicare/Medicare-General-information/Telehealth/Telehealth-Codes
- 2020 National Physician Fee Schedule Relative Value File, GPCI20, National Physician Fee Schedule Relative Value File Calendar Year 2020, MCR-MUE-Practitioner Services. Published by CMS. Effective: January 1, 2020.
- CMS.gov; “COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing” CMS.gov/files/document/03092020-COVID-19-faqs-508.pdf
- HHS.gov; “FAQs on Telehealth and HIPAA during the COVID-19 nationwide public health emergency” HHS.gov/sites/default/files/telehealth-faqs-508.pdf