COVID-19 Related Billing and Coding Considerations

Since the outbreak of COVID-19, we’ve seen an increase in mainstream telehealth, FaceTime for visits, waiving out-of-pocket expenses, working from home, and reporting office visit codes for telehealth services. However, all these go away as soon as the public health emergency is declared over. Like everything else, this too could change. This article outlines some of the changes made by Medicare in the wake of the public health emergency declaration. 

The first major change by Medicare during this public health emergency was coverage of telehealth services for mainstream practice. For patient encounters that take place via audio and video, it is appropriate to report the same codes and same place of service as if the patient was seen in person. For example, a follow-up visit with an established patient that takes place via audio and video would be reported with a code from the 99212-99215 series of codes. 

But that is not all. Medicare also made it easier to provide and document these services. Traditionally, HIPAA-compliant platforms were needed to provide telehealth. Now, it is acceptable to use publicly available, non-HIPAA compliant platforms such as FaceTime. 

Traditionally, documentation for these services would need to meet the requirements for two of the three key components of documentation: History, Exam, and Medical Decision Making. For telehealth services during this public health emergency, Medicare allows codes to be assigned based exclusively on Medical Decision Making. The other two variables should be documented to the level needed to assure quality and continuity of care, but they do not influence the level of service.

However, the challenge is figuring out exactly what is defined as Medical Decision Making. This is the one key component of documentation in the Evaluation and Management Documentation Guidelines that is open to interpretation. The guidelines indicate that there are three components of Medical Decision Making (ie, problems, data, and risk), and that two of the three must be met or exceeded. 

The variable of risk is quantified in the guidelines with a “Table of Risk.” It outlines examples that support each of the four levels of risk in three categories: presenting problem, diagnostic workup, and management options. The highest level of risk reached in any one of the three areas determines the level of risk. It is a lot easier than it sounds! If the patient has two or more stable chronic conditions OR if the clinician makes a decision regarding prescription drug management (including the decision to continue medications as prescribed), the level of risk will support a level four office visit (99214).

The Medical Decision Making variables of data and problems are not quantifiable based on information in the documentation guidelines or the CPT instructions. Medicare distributed an audit tool developed by the Marshfield Clinic to all contractors shortly after the guidelines became effective in 1995. According to Medicare, this auditing tool was not mandatory. Some Medicare contractors used it as provided, some made changes to it, and some dismissed it. It’s currently not possible to find exactly what the standard is in many states, as some contractors do not provide concrete guidelines; for example, some say that “medical necessity is the overarching criterion” without explaining how that translates to the four levels of Medical Decision Making. 

The alternative to coding exclusively based on Medical Decision Making is to code exclusively based on time. Traditionally, only face-to-face time was used to code office visits. During this public health emergency, Medicare says that office visits provided via audio and video could be coded based on the total time that the billing clinician spends on the date of the visit (to review records, establish connection, visit, documentation, etc.). 

One key change that Medicare made is specific to audio-only visits with patients. Codes 99441-99443 are used to report audio-only patient encounters. Traditionally, these services were classified as non-covered. Medicare changed the status of these codes to make them payable, and later increased reimbursement for these codes to match office visit codes 99212-99214. 

Unlike the office visit codes, these codes are exclusively coded based on time, and the only time that is given credit is clinical discussion time with the patient (records review, establishing the call, and documentation time do not count). Code 99441 is applicable if clinical discussion time is 5-10 minutes, code 99442 is for 11-20 minutes, and code 99443 is for 21-30 minutes.

Codes 99441-99443 come with a hitch: reimbursement for these codes is considered to be bundled into any visits (in-person or telehealth) rendered within the last 7 days or any visits that take place within 24 hours or scheduled for the next available appointment. 

Medicare has published that it is acceptable, not required, to reduce or eliminate out-of-pocket expenses for telehealth services provided during the public health emergency. For some Medicare patients, this could mean writing off 20% of the allowed amount. However, many Medicare patients have secondary insurance that typically pays for this 20% coinsurance. 

There are two modifiers to keep in mind when reporting telehealth services during the emergency: CS and 95. These have been moving targets since coverage for these services was introduced. Their appropriate usage will likely change by the publication of this article, so it is advisable to check either Medicare’s website or the author’s Twitter account (@CardiologyCoder) for the latest standard. 

The CS modifier indicates that “Cost Sharing” does not apply. The 20% coinsurance mentioned above is the cost sharing amount (ie, the patient shares that portion of the covered amount). The Families First Coronavirus Response Act (FFCRA) states that cost sharing does not apply to certain services (E&M visits) that ‘‘(iii) results in an order for or administration of a clinical diagnostic laboratory test described in section 1852(a)(1)(B)(iv)(IV); and (iv) relates to the furnishing or administration of such test or to the evaluation of such individual for purposes of determining the need of such individual for such test.”¹

Medicare has vigorously debated the interpretation of this statutory provision, and postponed addressing it for several weeks. Section (iii) suggests that a test must be ordered, but section (iv) suggests otherwise. At issue is whether the CS modifier should be reported for visits during which the doctor evaluates the patient to determine if they need the test but ultimately chose not to order one. On CMS’ May 5th Office Hours teleconference,² CMS said to only report the CS modifier for visits that result in the order for a test. They said that they are open to additional input and remain open-minded to different interpretations. 

The FFCRA specifies that the CS modifier can be reported with the office visit (audio and video) codes, but not the audio-only codes. The “no cost sharing” provision of the Act applies equally to virtually all commercial insurance companies as well. However, it is not clear if these payers will want the CS modifier used or if some other reporting mechanism should be used. It would be best to check with them.

The 95 modifier is defined as “Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System.” Despite the fact that this definition shows that the service involves audio and video, the latest guidance from Medicare on this subject (3/30/20 Interim Final Rule with Comment Period) is that we should attach the 95 modifier to all services on Medicare’s telehealth list, which is another moving target.³ The most current listing includes the office visit and audio-only visit codes featured in this article and many other services. The current list is located at https://go.cms.gov/3azOQuO.

This article has covered the most common telehealth services, such as established patient office visits and audio-only visits. It is important to note that there are other services on the telehealth list. There are also non-telehealth services that recently received attention (virtual check-in, e-visits). However, the virtual check-in and e-visit codes pay a lot less than the ones addressed above, and have more hoops to jump through (eg, documenting patient consent and keeping track of minutes spent over a seven-day period). 

Lastly, other services that may be provided remotely include remote monitoring of devices, remote physiologic monitoring treatment management, self-measured blood pressure readings, and principal care management.

Disclosures: The author has no conflicts of interest to report regarding the content herein. 

1. Families First Coronavirus Response Act. Congress.gov. Available at https://www.congress.gov/116/plaws/publ127/PLAW-116publ127.htm. Accessed May 6, 2020. 
2. Podcast and Transcripts. CMS.gov. Available at https://www.cms.gov/Outreach-and-Education/Outreach/OpenDoorForums/PodcastAndTranscripts. Accessed May 12, 2020. 
3. CMS-1744-IFC. CMS.gov. Available at https://www.cms.gov/files/document/covid-final-ifc.pdf. Accessed May 12, 2020.