Teleneurology Billing and Coding

Promoting Patient Access

Imagining that a new construct in health care would happen essentially overnight, was impossible 6 months ago. In early March, the World Health Organization deemed the coronavirus disease of 2019 (COVID-19) a pandemic, and the US federal government declared a national public health emergency (PHE). To protect its citizens, dramatic government interventions were made to maximize physical distancing. In order for beneficiaries to receive a wider range of services from their doctors without having to travel to a health care facility, the Centers for Medicare and Medicaid Services (CMS) catalyzed telehealth, thereby bringing health care directly to the people.

Telehealth is the broad term referring to various electronic and telecommunication technologies for delivery of virtual medical services and health education. Within this collection are 4 modalities.

1. Synchronous or 2-way, real time interactive audio and video

2. Mobile health, from targeted text messages promoting healthy behavior to wide-scale alerts about disease outbreaks

3. Remote patient monitoring, whereby data is transferred to providers in a different location

4. Exchange of medical information via store-and-forward or asynchronous digital communication (eg, images, documents, and prerecorded videos) is completed with secure email, patient portals, or other secure file exchange¹

The “History” of CMS Changes Because of COVID-19

Section 1135 of the Social Security Act allowed the Health and Human Services (HHS) secretary to temporarily waive or modify certain Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) policies. Along with the Coronavirus Preparedness and Response Supplemental Appropriations Act, passed on March 6, 2020, flexibilities of CMS allowed broadened access to telehealth services on a temporary and emergency basis during the COVID-19 PHE for people with Medicare benefits.

The process to expand telehealth access and reimbursement occurred in progressive steps at the federal level. Many state governments and commercial payors followed suit over the ensuing weeks. There are 2 notable sets of regulatory waivers and new rules by CMS.

March 17, 2020

CMS informed providers they could be paid for synchronous telehealth visits at in-person rates, retroactive to March 6, 2020.² The originating site could be the patient’s home. The originating site refers to where the Medicare beneficiary (the patient) is located, whereas the distant site refers to the location of the eligible health care provider. Coinsurance and deductibles could also be waived.

March 22, 2020

The submission deadline for the 2019 Quality Payment Program (QPP) was extended by CMS and offered neutral payment for 2021 if no submission was made by April 30, 2020.³

March 30, 2020

Parity reimbursement for more than 80 additional services by telehealth, including consultations in the emergency department, observation, inpatient, critical care, care planning, and neuropsychologic testing were allowed by CMS. Other changes include the ability to provide virtual check-ins to new patients (a change from the March 17, 2020 press release) and billing for telephone services (CPT 99441-99443). Additional waivers included removing telehealth visit frequency limits. Physician supervision could be done remotely, including patient care provided under an advanced practice provider.^4,5

April 30, 2020

Pay parity for phone services was agreed to by CMS with respect to evaluation and management (E/M) visits, matching levels 2 to 4 established outpatient visits based on time, retroactive to March 1, 2020.^6,7 There are 238 codes listed under Medicare telehealth services, with 135 codes temporarily added for the PHE for the COVID-19 pandemic.⁸

States’ and Commercial Payors’ Policies May Differ From Federal Policy

Among the many consequences of COVID-19, the pandemic shined a spotlight on some of the complexities of health care. Although federal regulations allowed for improved access to care, state laws could still preclude patient care via telehealth. For instance, in order to practice across state lines, state governments first needed to authorize providers without a license in that state. Providers also needed to affirm malpractice coverage when practicing telemedicine, as well as outside their originally approved jurisdictions.

Not every state government mandated commercial payors, Medicare Advantage, nor Medicaid to reimburse for services rendered by telehealth codes, let alone parity. Consequently, it has continued to remain the responsibility of the provider to understand current state mandates and local payor policies (See Quarantine Questions in this issue). Providers may find answers relevant to their locale through their in-network payors, resource websites (eg, The American Academy of Neurology [AAN] Telemedicine and Remote Care⁹ or the Center for Connected Health Care Policy Current State Laws and Policies¹⁰), state government websites, or their local neurologic or medical societies. With rapid changes to reimbursement policies, it is paramount that providers review billing more closely and continuously to ensure they receive accurate payment amounts.

Coding Management

During the PHE, coding and reimbursements evolved significantly. However, providers must also understand that these changes may continue evolving as our environment changes. The following commentary reflects current understanding and providers must be vigilant for additional modifications, either due to the ongoing PHE, or its resolution over time. It is also important to recognize practices may or may not need to collect coinsurance, deductibles, or copays depending on the payor. Each practice must weigh the pros and cons of these financial decisions. Nonetheless, patient consent to care must be obtained.

Coding by Time

To ensure accurate billing, providers should be comfortable in their understanding of evaluation and management (E/M) coding, including how to code by either medical decision making or time-based coding.¹¹ Because telemedicine precludes a full neurologic examination, providers may find coding by time (CPT 99201-99205; Table 1) to be more suitable.

Telephone Services and Digital Communication

Telephone E/M services are reimbursable by Medicare as well as many private payors during the PHE, at rates presently analogous to established patient E/M visits (CPT 99441-99443; Table 2). Telephone visits can be provided by a qualified provider to an established or new patient presently, but not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment. Patients must initiate the request for this service as well. Providers will be paid parity with E/M for phone visits, retroactively from March 1, 2020.

Virtual communication is also supported by CMS. Virtual check-in (CPT G2012) was designed to provide a brief communication by a technology-based service, including audio-only real time telephone interactions, that last 5 to 10 minutes in medical discussion. At this time, the practical value of this code is questionable given the opportunity to be paid parity for the telephone codes (CPT 99441-99443; Table 2). Other billable communications by technology include CPT G2010, whereby established patients can submit recorded video and/or images for the provider’s review. Of note, the provider cannot submit for billing of G2012 or G2010 if they originate from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment. The major change for G2012 and G2010 is coverage for new patients during the COVID-19 PHE.

Billing by providers for online digital E/M or e-visits (CPT 99421-99423; Table 3) is allowed by CMS. These are patient-initiated requests for evaluation and are billed based on cumulative time spent by the qualified provider (not including clinical staff) within 7 days. That is, the provider must track and document the time spent in communication with a patient. Examples of services included in these codes are secure communications through email and patient portal. Online digital E/M or e-visits cannot be reported on a day when the qualified health care professional reports E/M services or bills for remote monitoring, chronic care management, transitional care management, care plan oversight, or supervision of the patient in a home, domiciliary or rest home for the same communication(s).

Remote Monitoring

Remote monitoring, involving asynchronous transmission of information, can be used for established patients (CPT 99453-99455; Table 4) Examples include weight, blood pressure, pulse oximetry, and respiratory flow rate.¹²

Interprofessional Consultations

In order to minimize additional exposure to patients with active COVID-19 virus or in the context where advice is needed but a consulting provider is unable to provide a visit in a timely manner, or for other team-based care approaches there may be value in using an interprofessional consultation without the consulting provider interacting with the patient. There are 2 sets of codes that may be considered in this situation for a verbal and written report or for a written report only (CPT 99446-99449 or 99451-99452; Table 5). In either case, these codes require patient consent because copays may be charged to the patient if not waived by payor policy. These codes cannot be used if the consultation leads to a transfer of care within 14 days or the soonest available appointment date. More than 50% of the time cannot be spent in data review, and the codes should not be reported more than once within a 7-day interval. The codes should only be reported by the consultative physician, although the treating/requesting physician can also bill with CPT 99452 if the service takes 30 minutes or longer.

Place of Service and Modifiers

Place of service (POS) codes are used on professional claims to specify the entity where service(s) were rendered to inform payors.¹³ Prior to the PHE, telehealth services would use POS 02-telehealth, described as the location where health services and health related services are provided or received, through a telecommunication system.¹⁴ However, claims with POS 02 code are paid at facility rate, which is typically less than the nonfacility rate under the Medicare physician fee schedule. Consequently, during the PHE, CMS is directing providers in ambulatory settings outside of hospitals, skilled nursing facilities, community health centers, public clinics, and military treatment facilities (ie, private practice offices), to use POS 11 and modifier 95 in order to be reimbursed at the non-facility amount, or in-person value, for telehealth services (Table 6).

Modifiers are used when additional information may be beneficial to the payor or provider in order to get a claim paid in a timely manner. These codes are also used as a shorthand to explain specific details about a patient encounter. With respect to telehealth, 4 modifiers are typically considered, depending on the payor and service.

1. GT, meaning “via interactive audio and video telecommunications systems”

2. 95, meaning “synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system”

3. GQ, meaning “via an asynchronous telecommunications system.” This is for the federal telemedicine demonstration project conducted in Alaska or Hawaii

4. G0 (G Zero), meaning “telehealth services furnished for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke.”

Medicare discontinued modifier GT in 2017 when POS-02 (telehealth) was introduced. However, private payors may still use this modifier. Modifier 95 should not be used with in-person visits, virtual visits (G2012), or digital evaluations (99421-99423), although payors may vary in their approach to how telehealth claims are coded, nonetheless.

In the context of COVID-19 testing related services, the provider should use modifier CS on applicable claim lines subject to the cost-sharing waiver. As a result of the Families First Coronavirus Response Act (FFCRA), Medicare beneficiaries should not be charged for any coinsurance or deductible for those services. The CS modifier will signal the provision of a COVID-19-related service and indicate to the Medicare Administrative Contractors (MACs) to pay 100% of the Medicare-approved amount for the service. Physicians should contact their MACs and ask to resubmit applicable claims with dates of service on or after March 18, 2020, that were submitted without the CS modifier. The CS modifier should not be used for services unrelated to COVID-19.¹⁵

Conclusion

During the COVID-19 pandemic, telehealth rapidly became entrenched as not only a viable but a necessary care-delivery approach. As we move to another equilibrium after the COVID-19 pandemic, we may find our current coding and billing will change once more to meet the new challenges faced by society. Because innovation and change are parts of our current “PHE culture,” it is incumbent on all of us to better understand the new mechanics of care delivery and leverage this knowledge and experience to advocate for the right reforms to ensure our new health care system more closely matches what is right for our patients.