Welcome to Part 2 of our Q&A on Telehealth in the Time of COVID. If this is your first time reading, you can view Part 1 here, and watch the webinar, How to Accurately Audit in the Evolving State of Telehealth, where all of these questions were originally asked, here. As I previously mentioned, I’m only able to get to these questions during my free time, so please be patient if you haven’t yet received your answer.
Now, before jumping right into the Q&A, I want to first say that telehealth, and the regulations around this new approach to patient care, is a moving target. During these times of crisis, and when we get through them, telehealth regulations will no doubt be in a constant state of flux. What the answers below serve to support is the regulations as they exist today. It will be our goal to continue providing you updates around the coding and compliance regulations, as they are made public.
With that said, let’s get to your next round of questions.
(Editor's note: Some questions have been lightly edited for clarity.)
Since Annual Wellness Visits (AWV) are allowed by telephone, but we are told that they do not risk adjust, what is the benefit in doing them?
Risk adjust is based on diagnoses, not HCPCS or CPT codes. If a patient comes in for an AWV, you're going to get paid for doing it, so it should be billed. You get paid for services whether they risk adjust or not.
Telephone only – No prior visit, or next 24 hours visit – but they schedule a procedure for the next opening. Is this billable?
No, because CPT states: "Nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment."
If the patient is "scheduled" to see the provider, but during the COVID pandemic the patient is asked to stay home and the provider will call, would this be considered a patient initiated telephone service? The patient does not have video capability, so it is a telephone visit only.
Yes, but the documentation should still clearly state that. It should not just be assumed.
What if the telephone call is more than 30 minutes? - these don't have units.
You may be able to report the prolonged service codes, but you'll have to make sure to follow the guidelines for those in the CPT book.
What audit program do you use?
Healthicity Audit Manager - it's fantastic! Healthicity is a sister company to AAPC and AAPC Services. You can learn more here: www.healthicity.com/solutions/auditing/software-management
Is there any guideline for AWV vitals, patient reports, or vitals for an E/M? Is there a certain way this needs to be documented?
CMS just released an updated FAQ that discusses this question, which you can find here: https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf. Then, scroll to Question #23 under Section L.
Basically, the patient needs to have the equipment at home to report info to the provider, such as a scale, blood pressure monitor, etc. My assumption is that CMS is going to allow these visits even if the vitals cannot be obtained, since these are allowed to be performed via telephone only.
Can we bill Remote Patient Monitoring (RPM) example 99457 with 99441?
The telephone code cannot lead to a service that is related, including RPM. If the provider is performing the telephone visit for other reasons, then YES they can both be billed separately.
Can consent can not be inferred? If the patient goes on with the visit, wouldn’t that be considered consent?
Consent has to be documented at least annually, per Medicare. If you can reasonably assume consent, I would allow it. But the best practice is still to document it each time.
Are there any rules for the provider conducting a series of telephone calls to the patient? Say, the provider contacts the patient on 5/6, 5/11 and 5/17.
As long as it's medically necessary, and each call is at least 5 minutes, they can each be billed.
We were told we had to have Blood Pressure (BP) for an exam, even telemedicine visits. Can it be patient reported, or use the last known BP reading?
There is no federal rule about requiring BP. If your practice wants it, then a patient-reported BP is ok to use. However, the last known BP would not be.
Will the 'telephone only' visit work for risk adjustment HCC capture for CMS?
As of now, no. This is because they do not satisfy the face-to-face requirement. That said, we’ll await further info…
What would you suggest if you're still seeing pulled-in exam elements, and there is no time documented?
I do not count the exam unless I suspect this was a video visit. I have also seen provider's copy their exams forward. I do not count the elements and I make a comment on my audits that there is inconsistent information in the note. If there is no time on the telephone visit, I do not allow it at all, because time is a requirement.
For Pediatrics, can a physician have the parent perform parts of the exam, and use those exam components for the E/M? (Example: if the physician instructs the parent to feel the child's abdomen, can the physician then document "no tenderness or hepatosplenomegaly?"
Only if it is a video visit. I would educate the provider that he or she should be watching the parent perform the exam, the provider could then document what he or she sees.