Coding for Telemedicine Visits

Q: Do you know how the following patient care encounter can be somehow coded to reflect a physician's involvement via telemedicine?

An [advanced registered nurse practitioners] sees a patient and then remotely teleconference with a physician. The MD discusses the patient's care and ask/answer patient's questions via the teleconference with patient and ARNP. 

A: The scenario you describe below is a fairly typical telemedicine service as you describe it.

The codes 99201-99205, 99211 - 99215, the consultation codes 99241-9945 and others can be reported with the telemedicine modifiers QT or 95 depending on the payer.

As long as you perform and document the elements of history, exam and decision-making (or time spent counseling), and document them the same as you would as if you were there - and meet the basic conditions of a telemedicine visit - then you have a billable evaluation and management visit.

Medicare requires the GT modifier, and that the patient be in a HPSA (healthcare professional shortage area). Medicaid may or may not pay. Most large commercial payers will accept the 95 modifier as of 2017.

If you provide these services, document clearly the context and detail involved as above - select your code and append the modifier. Any further billing instructions would be determined by the payer.  

Q:   I work with a group of pediatricians in the hospital.  The question about review of systems (ROS) has come up for a newborn with a problem, (not a normal newborn exam) or an admission of a little one with a problem.  What do you do for ROS?  Rely on mom and dad for their opinion?

A:  Go online to CMS.gov and find a copy of the 1997 Federal Documentation Guidelines. Look at the last paragraph on page four and the first paragraph page five. It pretty specifically references the variances by certain groups, and names newborns - as being allowed to ‘depart’ from the general guidelines -which were written for the general adult population.

And of course a newborn can't talk - you get what you can from parents and state that it is the most complete ROS obtainable. It would be most unusual for a payer to bother a pediatrician about that.

Q:  I have a physician assistant that is billing an established problem visit code along with a new patient preventive visit code for an initial visit, such as a 99213 and a 99385.  I thought that an initial visit always had to report two new patient codes, and that we couldn’t mix them, such as one established code and one new code?

A: There are a few ways to look at this, but the bottom line is that there really isn't anything wrong with what this provider is doing. 

The reason I say this, and why most payers won’t mind this coding combination is because the RVU's match better for one of the services to be new, with the second service acting as more of an additional service.

The codes are set up such that a new service get a bit of an RVU bump just because it's new, and for one of those services you should get the full value because the patient is new. On the second service however, maybe you shouldn’t get the 'extra' part.

Think about the codes you mention - a 99385 includes a comprehensive exam, a 99203 would include an additional detailed exam - you can't really even do that - but maybe you can do some additional focused exam on a problem area.

The history of present illness and assessment and plan are unique to the problem code, but the preventive code includes all the rest of any work you’d do. It really is fair. Of course some coding purists will disagree, but most payers won’t.