As we are now well into 2021, and over 12-months from the beginning of the first announced PHE (public health emergency), the past year has been a whirlwind of medical practices having to pivot to a new delivery of care, Telemedicine. This platform also referred to as Telehealth, has seen an uptick of visits in the 80-90% range of overall patient outpatient encounters according to MGMA.

CMS and other Commercial payers adjusted their coverage policies to allow for these types of visits, virtual and remote care when the patient is in their home, and their care is delivered by an audio and video platform, or through a telephone call. The reason that the insurance payers have allowed Telehealth during the PHE, is to limit the spread of COVID-19 and to protect the most vulnerable to the virus, but still allowing for needed care.

Many pro-Telehealth entities and providers are advocating to continue with the current, PHE rules of Telemedicine delivery once the PHE end, but as the OIG stated in their 2021 Work Plan, assess the overall effectiveness of Telehealth and ensure it is not just a convenience over a medically necessary delivery of medicine.

With the 2021 Medicare PFS (Physician Fee Schedule) changes and the CMS C.A.R.E.S act Flexibility’s set to roll back once the PHE ends, what can you do now in your practice to prepare for potential changes in reimbursement and coverage?

The first thing to realize is, that the PHE is temporary.

Yes, the COVID-19 virus challenges may take us through the end of 2021 to slow, and as vaccines increase, there is a light at the end of the tunnel, but the PHE, in the truest of definitions, will end at some point. That will mean regulations will be rolled back; to what extent we are not completely sure, but we have the Social Security Act and CMS rules to follow and that cannot be changed unless an act of Congress does so and that takes months, even years to make happen.

In the CodeCast podcast, last November and December, I discussed this very question and how practices should handle the potential transition, once the PHE ends, also what is being audited since Telehealth services are now on the OIG Workplan for 2021. But the question, “Are you all-in on Telehealth or is this a stopgap during PHE?” has to be answered first.

How much is your practice willing to spend to make sure that your patients have equal access to an audio and video platform? Many patients still do not have the high-speed internet needed to engage in Telehealth services, and when the PHE ends, non-HIPAA protected platforms such as FaceTime and Skype will no longer be an option.

Also, one of the flexibility rules that will be rolled back to the original Telehealth regulation will be the “individual receiving the service must be located in a telehealth originating site”. This means, the patient’s home will not be an option, once the PHE ends unless the patient qualifies in an HPSA (Health Professional Shortage Area) area or is a mental health patient.

Under the CARES Act, Congress gave CMS the ability to waive the geographic location requirement during the COVID-19 PHE.

The current Public Health Emergency (PHE) is in effect through April 22, 2021, per www.phe.gov for certain RPM services through December 31, 2021  (the year in which the PHE ends).

CMS, in the 2021 Final Rule, grouped the Telehealth services into three categories as we navigate this next year during the PHE:

• Category 1: services/CPT/HCPCS codes that will become permanent after the PHE is over;
• Category 2: services/CPT/HCPCS codes that will be removed when the PHE expires; and
• Category 3: services/CPT/HCPCS codes added to the list, but only temporarily.

Category 3 codes, such as physical and occupational therapy, initial hospital care discharge day management, inpatient neonatal and Pediatric critical care, initial and subsequent may not remain after the PHE expires. CMS has also been clear that audio-only phone call codes, 99441-99442, will not be covered under the Telehealth provision, once the PHE ends, and created a new G-code G2252 as an 11-20-minute audio-only code cross-walked to code 99442 to allow for an encounter when the physician may not be able to have an encounter to visualize the patient.

We cannot foresee the future on where Telehealth is going, but as one recent CMS “Office Hours Calls” pointed out when asked about the patient’s home as a valid place of service (POS) continuing after the PHE ends, they stated “No”. Again, only for HRSA (rural Health Professional Shortage Area) or MSA (Metropolitan Statistical Area) patients, or for patients suffering from mental illness was that a possibility. That is a huge determining factor when a patient chooses to use Telehealth or not.

If they have to leave their house anyway to transport to an “approved” originating site, such as a hospital, physician’s office, or another medical facility, they might as well keep driving to their physician’s office if that is the only option. Commercial plans may allow more flexibility on this delivery of medicine since they are contract providers and can call their shots when it comes to coverage.

The healthcare consultants at NSCHBC want to advise our clients, and potential clients to do their due diligence, and determine if you will continue with offering Telehealth in the future in your practice, and what will be your business model for that offering? Most practices have said they will offer it, but it would be a good idea to survey your patients to find out what they would do if suddenly their home was not an approved site to receive Telehealth benefits.

Would they pay cash? Would they still engage? Or would they go back to the in-person care? A question for providers that have been using the PHE allowed smartphone device platforms such as FaceTime and Skype, “Will you invest in additional software to be HIPAA compliant?” These are questions to ask, as you prepare for another pivot in your delivery of medicine once the PHE ends.

Stay tuned to this ever-changing virtual delivery of medicine and how, after PHE, the reimbursement process will be handled and how it will affect continued payer coverage in medical practices.

You can listen to Terry expand on Telehealth in her weekly CodeCast Podcast available on all downloadable platforms.

 

References and Resources:

• https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf

COVID-19 Regulatory Alert: Medicare Telehealth Services Restrictions Lifted

Today, the Centers for Medicare & Medicaid Services (CMS) issued guidance on Health and Human Services (HHS) Secretary Alex Azar’s waiver authority that broadens access to Medicare telehealth services. Effective March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, CMS will:

• Waive geographic restrictions, meaning patients can receive telehealth services in non-rural areas;
• Waive originating site restrictions, meaning patients can receive telehealth services from their home;
• Allow use of telephones that have audio and video-capabilities; stored information
• Encounter has to be patient initiated
• Allow reimbursement for any telehealth services “covered code”, including Office Visits (99201-99215), even if unrelated to COVID-19 diagnosis, screening, or treatment; and
• Will not enforce the established patient relationship requirement, as determined by CPT Guidelines that a patient see a provider within the last three years.

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The Medicare telemedicine healthcare provider fact sheet can be found at:

• https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

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The Medicare FAQ on these telehealth waivers can be found at:

• https://edit.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf

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The Enforcement Discretion for telehealth remote communications during the COVID-19 notice can be found at:

• https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html

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Expect more updates on this in the days and weeks ahead!

 

How To Register

Please join Terry Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, ACS-CA, SCP-CA, QMGC, QMCRC, QMPM for an on-demand webinar on how to implement these changes and more.

You can register for this session by clicking the button below and scrolling to the down to the register section.

Cost: $299.

Note: This webinar has been updated and replaced by Telehealth OnDemand Webinar: CMS and Other Payer Updates which you can register for at the same link below.

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AMA is on track to revise E/M codes and set new documentation guidelines. What was considered to only target the Office and Other Outpatient visits, has now been expanded to impact the entire E/M section of CPT®.

The AMA’s CPT® Editorial Panel approved many changes to the Evaluation and Management documentation and coding guidelines. If finalized, the changes will shift the way medical practices select codes for both office and facility visits as soon as January 2021.

The Approved Changes

Deletion of level 1 office new patient E/M code 99201.

(For Medicare, claims for code 99201 represented only 0.15% of all 266 million inpatient E/M claims in 2017, when it had a 37% denial rate (versus an overall E/M denial rate of 5%).

Understand the History and Exam CHANGE before you proceed

AMA’s Panel agreed to the removal of history and exam as key components for selection of the E/M service level. This means that the history and exam would not be used to “score” the visit for an audit. However, the practitioner would be required to document that these elements were performed in order to report an office visit code. Evidence of the history and exam should still be part of the documented record.

Practitioners would select E/M codes based on either 1) the level of medical decision making (MDM) or 2) the total time spent performing the service on the day of the encounter. (Note: “time” will limit you on how many patients you can see per hour).

A plan to revise the E/M guidelines into three sections

• Guidelines common to all E/M services,
• Guidelines specific to office and other outpatient visits and
• Guidelines specific to E/M services in the facility setting, including observation, hospital inpatient, consultations, emergency department, nursing facility, domiciliary, rest home or custodial care and the home setting.

Total time would include “total time spent on the day of the encounter,” instead of total face-to-face time of the visit.

A major overhaul of the MDM documentation guidelines to emphasize complexity of the conditions being addressed in place of the number of diagnoses reported.

Within the office and outpatient E/M guidelines, MDM section title updates would include:

• “Number of Diagnoses or Management Options” would become “Number and Complexity of Problems Addressed;”
• “Amount and/or Complexity of Data to be Reviewed” would become “Amount and/or Complexity of Data to be Reviewed and Analyzed;” and
• “Risk of Complications and/or Morbidity or Mortality” would become “Risk of Complications and/or Morbidity or Mortality of Patient Management.”

Among the additional proposed changes

Prolonged services

AMA proposes to make some changes to other E/M codes; for example, they would revise prolonged E/M or psychotherapy service codes 99354 and 99355, which currently say “in the office or other outpatient setting,” to “exclude reporting of Office and other Outpatient Services codes. Also, a new 99XXX code would be added to “report prolonged office or other outpatient E/M services.” Guidelines would be revised.

Interesting inclusion

AMA proposes to add guidelines for reporting time “when more than one individual performs distinct parts of an E/M service.” This will need to be clarified as to what constitutes the clinical team as part of the encounter.

Summary of changes

AMA proposes to add a Summary of Guideline Differences table to denote the differences between the different sets of guidelines, as well as new definitions of terms, a new MDM table, and definitions of total time associated with outpatient E/M codes. The CPT editorial panel is seeking comments through March 25. Details are available on the AMA CPT website.

 

(A version of this article was referenced from Part B News)

There seems to be a lot of confusion that the E/M codes and levels are changing in 2019. This is NOT accurate. The changes to the levels of E/M’s and reimbursement will not occur until 2021.

Here is what is happening in 2019. Everything is spelled out in this link.

The four bullet points below for 2019 and 2020 really do not reflect anything different from what is already required and has always been required, except for the first bullet. (See highlights below.)

For CY 2019 and CY 2020, CMS will continue the current coding and payment structure for E/M office/outpatient visits and practitioners should continue to use either the 1995 or 1997 E/M documentation guidelines to document E/M office/outpatient visits billed to Medicare. For CY 2019 and beyond, CMS is finalizing the following policies:

• Elimination of the requirement to document the medical necessity of a home visit in lieu of an office visit;
• For established patient office/outpatient visits, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so; italics and underline is for emphasis
• Additionally, we are clarifying that for E/M office/outpatient visits, for new and established patients for visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information; and Again, has always been required
• Removal of potentially duplicative requirements for notations in medical records that may have previously been included in the medical records by residents or other members of the medical team for E/M visits furnished by teaching physicians. This might provide a little relief.
• The -25-modifier reduction when applied to an E/M on the same date as a minor procedure, did NOT pass. This discussion is tabled for further review into 2020.
• Communication based services for 2019 – Codes 99446-99452 will be available for a physician and/or NPP to bill in the final 2019 Medicare physician fee schedule and are not subject to the same rules or restrictions as Medicare telehealth services. There is no originating site or geographical area qualification to be eligible for services. However, there are many hurdles to consider before submitting these codes for payment.

Enroll in my 2019 CPT update for details.

In what is being reported as the biggest change of its kind in more than two decades, the Centers for Medicare & Medicaid Services (CMS) plans to redefine the documentation requirements for evaluation and management (E&M) coding in 2019, along with flattening payments for new and established patient office visits to a single pay system. The proposal offers $93 for established office visit codes (99212-99215) and $135 for new patient visits (99202-99205).

CMS is proposing to forego the 1995 and 1997 guidelines for what is being reported as a “simpler model” that will eliminate the need to re-document redundant information from prior visits and instead focus on medical decision-making. CMS is also proposing to blend patient E&M encounters into one specific relative value unit (RVU) because in their opinion, documentation is based on the ability of providers to get into their electronic medical records (EMRs) to find additional information other than what was noted.

But what is missing in all this is the reality of the reimbursement concerns, especially for specialty physicians who are taking care of sicker patients who need more time, effort, and higher levels of care to manage their complex issues.

This proposal will in effect penalize those physicians in specialties such as oncology (7 percent reduction), neurology (7 percent reduction), cardiology (3 percent reduction), pulmonary (3 percent reduction), rheumatology (7 percent reduction), and nephrology (3 percent reduction), to name a few. This does nothing to cut spending under the Medicare program, but more redistributes money among physicians.

Instead of the American Medical Association (AMA), in conjunction with Medicare, adopting a new code set, CMS is attaching the same RVU to the level 2 through 5 codes for both new and established patients, which creates the same payment amount. Most of the impact will be focused on 99214 and 99215, with a 15 percent cut of about $16-$23. These codes are about 89 percent of all allowed services, according to CMS data, and practices routinely billing the 99204 new patient code would see a 13 percent decrease in reimbursement. Your E&M profile would determine if you are in the “win” or “lose” column with this proposal.

Modifier 25 could be used as a reduction edit for CMS, not protection for your E&M encounters.

Also included in the 2019 proposal is the multiple payment reduction proposal. How many times do you place a modifier 25 on an E&M service when providing a second service (i.e., a skin tag removal, an injection, a diagnostic test, etc.) on the same day? Often done for patient convenience and for physician efficiency, CMS is proposing to reduce reimbursement for such services by half (the national equivalent of $47-$68 on a sick visit encounter). This reduction model previously has only been applied to surgical procedures, when multiple procedures are performed during the same surgical event. The impact of this change on physician office-based and outpatient-based services would be dramatic.

Modifier 25 serves as a true indicator of a:

Significantly, separately identifiable evaluation and management service above and beyond the pre-service workup of a procedure, performed on the same day by the same physician

As such, it should remain untouched to ensure that all Medicare beneficiaries are provided appropriate care and evaluations and are not forced to make repeat visits, resulting in increased co-payments and out-of-pocket costs, not to mention unwarranted, burdensome, and expensive travel back to the office!

Coding multiple PCI in one vessel for Cardiology:

Question: My Cardiologist placed a DES (Drug Eluding Stent) in the right coronary artery, and then did several passes in the proximal right coronary with the atherectomy device, and post ballooned the same vessel. How do I capture all of these services?

Answer: You’ll report the code 92933 (Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty, when performed; single major coronary artery or branch). This covers all 3 procedures, when performed in the same major coronary artery.

Reporting Smoking and Tobacco-Use Cessation Counseling:

Question: Our physician recently started adding documentation to his daily note when discussing with patients, who are current smokers, the benefits of quitting, treatment options for quitting smoking, and also how this may effect the patient’s recovery if they do not quit. Can I charge extra above and beyond the office visit encounter for this discussion?

Answer: Yes, you can report smoking and tobacco-use cessation codes 99406 or 99407, depending on how much time is documented for this discussion. The 99406 states “..3 minutes up to 10 minutes..” and the 99407 states “…greater than 10 minutes..”. Exact time, in minutes, should be documented within that encounter to accurately capture the service. You may need the 25 modifier on the E/M service to allow payment for both services on the same date.

CMS has been clear that this must be clinically appropriate, (e.g. patient is a current smoker with symptoms), and time must be documented.

Billing for Moderate Sedation with minor procedures in the facility setting:

Question: In 2017 we are aware that moderate conscious sedation can now be billed separate to many procedures, as long as our physician documents that he/she supervised the sedation trained nurse, what medications were used, and time is also documented. We are only getting paid for the fist 15 minutes, and sometimes the time documented can be over an hour. How can we get the payers to pay for the entire time documented?

Answer: When these services were priced, the physician RVU file for CMS, there is a column labeled “PCTC IND” which designates when a code is technical-only or professional-only. The add-on code for each additional 15 minutes of moderate sedation by the physician performing the procedure (99153) is indicated as technical-only (3) in this field. In addition, there is an NA in the RVU file column titled “FACILITY NA INDICATOR”. The NA indicates “that this procedure is rarely or never performed in the facility setting”. Since code 99153 is technical only, a physician cannot report this code when performed in the facility setting. Meaning only the first 15 minutes is payable (Medicare) in the facility setting. Any location that is not POS 11.

Gastroenterology Screening Colonoscopy:

Question: My physician performs screening colonoscopies at the request of a primary care physician or a patient that self refers to our clinic. We have started to notice that we are not getting paid for any of our initial consultations or office visits when a screening colonoscopy is requested, why?

Answer: First, the patient was not sent to your office for an evaluation of a sign, symptom or indication. There is no problem-oriented visit. They were sent over for a “screening”, which usually means the patient has a family history of colon disease or is age appropriate for a screening, but asymptomatic. These encounters are considered not billable, per CMS and AGA, even though the physician needs to take a history on the patient before proceeding with the screening. This can be done through a series of Q&A’s over the phone with the mid-level clinician, RN or MA. There is no e/m component to be billed unless the patient is having symptoms that need to be addressed prior to the endoscopy procedure, but then that could mean that the screening is negated and it is now a diagnostic procedure. The AGA (American Gastroenterology Association) recommends that for a true screening, the patient be considered “open access” and go directly to outpatient scheduling for the procedure. If the physician chooses to bring the patient in for a “meet and greet” that is not a billable service, but may be a cash charge to the patient.

Below is a starting point of your billing service checklist.

Make sure you receive answers to these questions from your potential new billing company before you sign a contract and know what you are getting and what they are giving.

(For a complete list, please join our onDemand Coding Corner Membership service.)

1.  Years in Business?
2.  Computer Software Vendor?
3.  Client Count?
4.  Client Count in specialty?
5.  Provider Count?
6.  Staff Count?
7.  Client Turnover Rate?
8.  Processing Methods?
9.  Specialties Served?
10. Fee structure?
11. Cash Management
12. EOB Management
13. For a complete list, please join our onDemand Coding Corner Network Membership: https://www.terryfletcher.net/coding-ondemand/

A recent news release from AMA regarding the use of Telemedicine states:

Telehealth and Telemedicine are another stage in the ongoing evolution in new models for the delivery of care and patient-physician interactions.

AMA Board member Jack Resnick MD also added:

The new AMA ethical guidance notes, that while new technologies and new models of care will continue to emerge, physicians’ fundamental and ethical responsibilities do not change.

Medicare will pay for both a facility fee to the originating site and a separate payment to the distant site practitioner who provides the service only if the telemedicine service meets all of the following stipulations:

1. A physician or other authorized practitioner must provide the telehealth service(s).
2. The patient who receives the telemedicine service(s) must be enrolled in Medicare Part B and receive the service at an approved/accepted telemedicine originating site.
3. The qualified physician must employ interactive, real time, two-way telecommunications equipment that includes both audio and video when he/she provides the telemedicine service. This means services through a face-to-face live video conferencing technology.
4. The service must appear on the Medicare’s list of approved telemedicine services.

We will be posting a Telehealth Services FAQ’s on December 1st, 2017.

CMS issued a late update to the Medicare Part B Deductible that was posted to the CMS web site on 01/02/2017

Part B deductible & coinsurance

2017 will bring a raise to the Part B Medicare deductible. It is going up to $183 per CY from $166 in 2016. Remember the 2% sequestration deduction from Medicare payments continues to be in effect until our new Administration can bring this to President Trump’s attention to change it. Stay tuned.