Humans may fear change as a general rule, but we’re adaptable when we need to be. In this era of COVID-19 and social distancing, medical practices and payers are adapting to an increased use of telemedicine, which enables providers to see their patients without being in a room with them.
To cope, the Centers for Medicare & Medicaid Services (CMS) and commercial payers have relaxed their rules regarding telemedicine.1,2 Things are still evolving, so it’s important for rheumatology practices to stay up to date on the appropriate billing codes—including new codes from the International Classification of Diseases, 10th Edition (ICD-10) related to COVID-19—and other guidelines surrounding telemedicine. ACR staff is monitoring these changes and has compiled a collection of online resources to help practices glean the most important details.
Telemedicine Expansion
Before the current public health emergency, rheumatologists could practice telemedicine only in certain circumstances, such as to help patients in rural areas. But with stay-at-home orders being issued across the country, it became necessary for the CMS and other payers to update their guidelines so physicians could safely continue treating patients.
On March 17, the CMS announced expanded allowances for telemedicine on a “temporary and emergency” basis. Most third-party payers—including the big four, UnitedHealthcare, Aetna, Cigna and Blue Cross Blue Shield—have followed suit.3-6
The CMS specifies three main categories of telemedicine appointments that can be submitted for reimbursement:
- Telehealth is a visit with a patient in which the provider uses an audio-video or audio-only telecommunications system;
- A virtual check-in is a brief check-in with a patient using a recorded video and/or images submitted by the patient; and
- An electronic visit, or e-visit, is communication with a patient through an online patient portal.
The ACR Telehealth Provider Fact Sheet and FAQ provide an overview of telemedicine, including information on billing and coding, licensure, state actions and more.7
Telemedicine Coding & Billing
With the expanded use of telemedicine, medical practices need to adjust their coding and billing procedures. This includes using the new ICD-10 codes related to COVID-19, as well as following new and evolving rules regarding place of service codes and modifiers for telemedicine.
Keep in mind that the CMS and the various commercial payers handle their updated rules differently, says Antanya Chung, CPC, CPC-I CRHC, CCP, ACR director of practice management. She and other staff at the ACR investigated these variations in compiling the ACR Telehealth Coding Reference, a quick reference guide intended to help rheumatology practices navigate telehealth coding and billing requirements.8
“There were different payer guidelines, [so] we needed to make sure our membership had as much information as they possibly could for their staff to be able to continue to have a fairly good workflow with patients, because the patients are still coming in,” Ms. Chung said.
Part of updating coding and billing practices is being aware of the two new ICD-10 codes related to COVID-19:
- U07.1—“COVID-19, virus identified” is assigned to a disease diagnosis of COVID-19 confirmed by laboratory testing.
- U07.2—“COVID-19, virus not identified” is assigned to a clinical or epidemiological diagnosis of COVID-19 where laboratory confirmation is inconclusive or not available.
In addition to the new ICD-10 codes, there are new requirements related to billing for telemedicine visits, which depend on the type of visit and the insurance carrier’s policies. Many of these policies are in line with the CMS, but there are differences, Ms. Chung said.
“With all the telehealth rules and different carriers having different rules, you must verify the patient’s insurance carrier to understand their telehealth visit guidelines,” says Melesia Tillman, CPC, CPC-I, CRHC, CHA, ACR reimbursement specialist. To make it more challenging, the rules keep changing. To help, ACR has provided a Commercial Payer Temporary Telehealth Policies[KR10] document, which links out to third-party payer telemedicine policies, lists effective dates, and provides other details for various carriers.9
As an example of rule changes, Medicare originally required that practices use “02” for the place-of-service code, denoting a telehealth visit, but then switched it to “11,” which is an in-office code. This was done so the reimbursement amounts would be more accurate, Ms. Tillman explained. The CMS also added “95” as a modifier (to be entered on the claims line for services furnished), which identifies telemedicine as opposed to an in-person evaluation and management (E/M) visit.
Another update to billing and coding practices is that Medicare is allowing the use of its revised 2021 E/M guidelines. The new guidelines allow physicians to choose whether their documentation is based on medical decision making or on total time, as discussed in a recent article from the American Medical Association.10 Total time used for billing includes physician time, as well as other providers’ time (such as nurse practitioners or physician assistants), but not ancillary staff time, Ms. Tillman explains.
Further, billed time can be spent on the patient visit and related activities, such as charting, calling in prescriptions and reviewing laboratory results, “so long as you do it on the same date as the actual telehealth visit,” Ms. Tillman says.
In addition, the time allowed for visits has been expanded in the 2021 E/M guidelines. For example, the CMS allowed 25 minutes for a level 4 established patient, but the new guidelines allow up to 40 minutes, Ms. Chung says. This will allow providers to bill to the highest level of specificity for each visit, she adds, and this change should be beneficial in terms of providers being able to spend needed time on patient care.
Resources at Hand
In the end, the key is to stay informed with the new guidelines to help ensure practices keep running smoothly, claims don’t get rejected and reimbursements continue coming in.
“We encourage practices to use the ACR resources, which have been verified with both the CMS and private payers for what is available to them,” Ms. Chung says. “We hope these will be convenient and valuable resources for practices.”
Members can also contact ACR staff if the information they need isn’t on the ACR website: [email protected].
Kimberly Retzlaff is a freelance medical journalist based in Denver.
References
- Medicare telemedicine health care provider fact sheet. Centers for Medicare & Medicaid Services. 2020 Mar 17.
- American College of Rheumatology. Commercial insurers extend coverage for telehealth services. The Rheumatologist. 2020 Mar 27.
- COVID-19 telehealth services. UnitedHealthcare. 2020 Apr 14.
- COVID-19: Supporting our providers. Aetna. 2020 Apr 13.
- Cigna coronavirus (COVID-19) interim billing guidance for providers. Cigna. 2020 Mar 17.
- Media statement: Blue Cross and Blue Shield companies announce coverage of telehealth services for members [news release]. Chicago, Ill.; BlueCross BlueShield. 2020 Mar 19.
- ACR telehealth provider fact sheet and FAQ. American College of Rheumatology. 2020.
- ACR telehealth coding reference. American College of Rheumatology. 2020.
- Commercial payer temporary health policies. American College of Rheumatology. 2020.
- Robeznieks A. E/M prep: Your in-house practice checklist for 2021 transition. American Medical Association. 2019 Nov 5.
