We have been speaking with many of you directly as states react differently to the arrival of the coronavirus in the United States. Stay-at-home orders and canceling of elective surgeries are spreading at the time of this writing. Many urology practices have already seen massive cancellations of in-office visits and surgical services. Others are preparing for changes that are coming.
As we hear from urologists and practices around the country, the primary concerns are centered around continued care for patients while maintaining the health and safety of both patients and staff. We have heard of many new and creative solutions for social distancing in the office setting for those patients requiring face-to-face care. It is impressive to see the talent and intelligence of the urology community.
We have also been impressed with the efforts of industry and the specialty organizations to help urologists stay up to date, push for legislative actions that allow for appropriate continuity of care, and in keeping the urology community at large in touch with one another. Keep thinking, keep planning, keep watching, and keep sharing. It takes a village, now more than ever.
For this article, we will focus on telemedicine and telehealth services. We will share what we know at this time, but know that changes are happening very quickly as payers, the government, patients, and practices react to this unprecedented crisis. There are several websites we encourage you to monitor to keep abreast of changes (see “Online coding resources”).
In discussing the various options for remote services, we will first establish a vocabulary. Although many use these terms interchangeably, we are going to separate services into the following categories:
Telemedicine is the use of synchronous audio and visual communications to deliver health care at a distance.
Telehealth is the use of electronic and telecommunications technology to deliver asynchronous health care at a distance.
Several platforms available
There are a number of platforms that will allow you to interact with your patients using audio and visual communication. Prior to the COVID-19 outbreak, Medicare provided coverage to more than 100 CPT services as long as patients receiving care were located in a Medicare-approved facility located (“originating site”) in a Health Professional Shortage Area (HPSA). The list of covered services included evaluation and management services, mental health, opioid addiction care, end-stage renal disease services, and other services deemed medically appropriate.
During this crisis, Medicare has relaxed several of the requirements for providing and billing for telemedicine services because during this public health emergency they believe patients should avoid unnecessary travel to physicians’ offices, clinics, hospitals, or other health care facilities where they could risk their own or others’ exposure to further illness. Here, we provide a summary of the changes and how they affect the urology office.
Medicare relaxed the originating site requirements and the HPSA requirements during the outbreak. Therefore, established patient outpatient visits 99212-99215 can be reported when provided to any patient regardless of the patient’s location as long as the visit is conducted using a live audio and visual connection. Documentation for the visits has been relaxed and allowing level selection to be based on time spent that date related to the service or Medical Decision Making.
Payment for each code will be made at the same level as if the service were provided face to face in the outpatient setting. Billing requires you report the code for the visit using place of service 11 (the place-of-service code for office). A physician can provide these services from their home or other appropriate location. For purposes of billing, the location address for services should be the office number assigned to your Provider Transaction Access Number regardless of the actual location of the physician.
CMS has clarified that it will not enforce the requirement that remote services be reported only for patients with whom the physician has a prior relationship, allowing you to provide new patient visits remotely (99201-99205). Documentation requirements are also relaxed, allowing level selection based on Medical Decision Making and time the same as established patient visits.
Medicare beneficiaries are generally liable for their deductible and coinsurance. However, to reduce the potential financial burden on Medicare beneficiaries, the Department of Health and Human Services Office of Inspector General stated they would provide flexibility for health care providers to reduce or waive cost-sharing for telehealth visits paid by federal health care programs. Should you choose to waive co-payments for these services, be careful to be consistent when offering this to patients. This option has been announced and may be expected by patients.
You may wish to develop a process for telemedicine visits that includes having the front desk speak with the patient with regard to billing and payment, having a medical assistant or nurse assist you to collect relevant history complaints and making sure the video and audio connection is of sufficient quality, and finally commencing the visit with the physician. The first two steps, up until the establishment of the connection, can be conducted with audio (telephone) only and can be accomplished prior to the visit similar to the flow established for an in-office visit.
Multiple options for obtaining patient forms/signatures
Forms typically required for new patients, including release forms, HIPAA policy explanation, and financial policies, can be obtained through patient portals. CMS has stated that forms can be signed after the visit has been provided and can be blanket coverage for an annual period, a verbal consent should be obtained and documented in the patient record.
As not all patients are well versed in the portal or use of the Internet, under the relaxation of HIPAA during the crisis, you should be able to use services like DocuSign to acquire patient signatures and other documents normally required when a new patient joins the practice. It also appears that you would be able to send forms via email and receive a scanned document (encrypted if possible) or returned via picture and messaging to the office; use this as a last resort.
Numerous applications can be used, such as What’s App, that allow pictures to be sent in an encrypted format directly from a phone to a computer instead of using mobile phones in the office.
HIPAA rules have been relaxed as well. You are free to use FaceTime and Skype to conduct these visits without a Business Associate Agreement for CMS. You are required to take reasonable precautions such as avoiding the provision of these visits without others in the room who are not employed by your office. Further, we encourage you to respect your patients, explaining the purpose of others required in the room. If you have HIPAA-compliant tools, you should use them when possible.
In 2019, CMS expanded the ability to provide services remotely by adding new codes and extending coverage to new CPT codes for services provided using the telephone and other telecommunication platforms. The expanded coverage for these services prior to the COVID-19 outbreak required that the patient was an established patient, the patient initiated the encounter, the encounter was not related to an E/M visit provided in the last 7 days, and the visit did not result in instructions to have the patient come to the office at the next available appointment. The codes for these services and the descriptions are provided in the table.
G2012 (Brief communication technology-based service, eg, virtual check-in) is intended for telephone calls initiated by a patient that are not related to or in follow-up of a recent E/M service for which the provider can manage the patient on the phone and the call does not lead to an in-person visit. It is important to document in the chart that the patient met these criteria, consented to the call, and understands that a bill will be sent to Medicare.
Code G2010 is a similar code, but when there is asynchronous (not real time) services provided (“store-and-forward”). During the COVID-19 outbreak, CMS has stated clearly that these services and six new service codes for Telephone only services 99441-99443 and 98966-98968 can be provided to new and established patients expanding the ability for continuity of care for your patients. The requirement for patient initiation of these visit types has also been relaxed during the crisis.
Finally, in regard to these services, if the patient requests a visit of this type but it is determined by the physician or advanced practice provider that a telemedicine visit is more appropriate given the patient complaints, the staff should communicate that the nature of the problem requires a telemedicine office visit. We recommend that scheduling staff be well trained to communicate the differences and circumstances.
Other codes are available that are intended for encounters performed using a patient portal or other HIPAA-compliant communication method. Check with your insurers to see which codes may be covered.
Medicare Advantage. Medicare Advantage plans are expected to allow for coverage under Medicare guidelines or establish guidelines that are less stringent. In 2019, Medicare relaxed requirements for Medicare Advantage plans to be restricted to Medicare rules. Therefore, Medicare Advantage plans can offer more services or establish rules that provide additional services than those allowed for Medicare. Check payer websites for guidance. Some of these payers may allow telephone visits for established patients to be reported with established patient visit codes (99212-99215). Billing for Medicare Advantage plans should require only use of the appropriate CPT code with place of service 11 and modifier –95.
We have been following the Medicare Advantage plans, and in general most allow for coverage under the relaxed rules and have gone beyond Medicare to allow additional services to be provided remotely. Many payers have indicated that the patient co-payment for remote services will be covered by the payer, meaning the group will be paid the full allowed amount by the insurer.
Medicaid. Medicaid programs are directed by the state. You will need to check with your state Medicaid program for coverage rules and billing for telemedicine and telehealth services. However, most states are relaxing requirements for remote services.
Commercial plans. Many commercial payer plans have policies that follow Medicare guidelines as they are published. With the emergency declaration, the larger payers have already released policies allowing for expanded coverage of both new and established office visits. Further, many of these payers are waiving patient responsibility for remote visits, promising to pay the full allowed amount for the encounters.
Some payers, in addition to using place of service 02, are requiring the use of modifier –95 (Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System: Synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. The totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. Modifier 95 may only be appended to the services listed in Appendix P. Appendix P is the list of CPT codes for services that are typically performed face-to-face, but may be rendered via a real-time [synchronous] interactive audio and video telecommunications system.)
Some payers may require place of service 11 and modifier –GQ, –GT to report these services.
Telehealth is a viable tool to solve the continuity-of-care issues faced during the coronavirus restrictions. Patients appear to be adapting to and even liking the new format. We would encourage you to adopt HIPAA-compliant practices as soon as possible but use the relaxed enforcement declaration to take care of your patients in need. We are projecting that after the outbreak remote visits in the form of telehealth and telemedicine will remain an option for patient care.
As you move past the initial scramble to reschedule and retool your practice, develop protocols and policies that will allow you to adopt telehealth and telemedicine technologies for patient care under new policies that will likely fall somewhere between where they were and where they are for the crisis.