Focused Coding Education Expanded Telehealth Services

Coding Quality Education

Physician Services Division

AGENDA

§ Overview of Telehealth Services and Mode of Communication

§ Optional Service – “Virtual Check-In”

§ COVID-19 ICD-10 Coding Rules

§ COVID-19 Coding Scenarios

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To address the declared Coronavirus (COVID-19) Public Health Emergency (PHE), the Telehealth services were expanded under a new waiver in Section 1135(b) of the Social Security Act.

WHAT DOES THIS MEAN?Under this new telehealth waiver, patients will be able to receive a wider range of health care servicesfrom their providers without having to travel to the office. To ensure a viable solution is available to ourproviders to see patients via telemedicine under this temporary waiver, we are implementing“BlueJeans” as the mode for virtual communication between the provider and the patient.

WHEN DOES IT EXPIRE?The telehealth waiver will be effective until the PHE declared by the Secretary of HHS is revoked.

WHAT IS THE COST SHARE TO THE PATIENT? Certain payors have waived cost sharingAny patient responsibility will be appropriately accounted based on claim processing.

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TELEHEALTH SERVICES

TELEHEALTH SERVICESDEFINATION:• The Centers for Medicare & Medicaid Services (CMS) defines telehealth services to include

those services that require a face-to-face meeting with the patient delivered via a telecommunication system substituting in-person encounter.

Mode of Communication:• HMHMG will be utilizing BlueJeans platform for patient interactive servicesWHO CAN PROVIDE THIS SERVICE?

• Physicians• Nurse Practitioners• Physician Assistants• Certified Nurse Midwife• Clinical Psychologists,• Licensed Clinical Social Worker• Registered Dietician

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TELEHEALTH SERVICESWHAT TYPE OF SERVICES?

• Evaluation and Management visits (common office visits) 99201-99205; 99212-99215• Preventive Health screenings (Annual Wellness Visit)• Individual psychotherapy 90832–90834 and 90836–90838• Transitional care management: 99495 - 99496• Medical Nutrition Therapy 97802 – 97803• Remote Patient Monitoring e.g. Glucose monitor. Telehealth modifier is not applicable.

Modifier (Providers are required to add GT modifier only. System will fire appropriate rule for applicable modifier per payer policies.)

• GT-Via interactive audio and video telecommunications systems.

• 95-Synchronous Telemedicine Service Rendered via Real-Time Interactive Audio and Video Telecommunications System.

• GC-This service has been performed in part by a resident under the direction of a teaching physician.

POS 02 (Based on payor specific guidelines)

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TELEHEALTH SERVICES

TELEHEALTH SERVICES WITH RESIDENTS

• Teaching Physician can provide concurrent services with medical residents through interactive audio/video platform.

• Append GC modifier with applicable telehealth modifier.

Telemedicine Teaching Physician Attestation: .ATTESTRES-T

I evaluated @FNAME@ @LNAME@ on @dos via audio/visual communication concurrently with {Medical Trainees: 23897}. I discussed this patient with the {Medical Trainees: 23897} and agree with the documented findings and plan with the additions/corrections as noted below.

Additions/corrections:{Additions/Corrections: 23901}.@ME@Attestation note date: @TD@Attestation note time: @NOW@

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TELEHEALTH SERVICESDOCUMENTATION REQUIREMENTS:1. Patient, parent, or legal guardian needs to be educated on the use of Telehealth visit.Example: It is imperative during this public health emergency that patients avoid travel,

when possible, to physicians’ offices where they could risk their own or others’exposure to further illness. The telehealth visit in lieu of an in-person visit helpsto reduce this risk.

2. Provider needs to obtain verbal consent before proceeding.3. Provider attestation is required as follows.The (***){telehealth relationship:30463} was educated on the use of a telehealth visit in lieu of anin-person evaluation. The (***) {telehealth relationship:30463} has agreed to be evaluated viainteractive audio and visual communication at this time.4. Use Epic smartphrase .attestTeleHealth to document the attestation.

5. Est patient: Same as an E/M in the office with the exception of an “Exam”

6. New patient: Same as an E/M in the office including an “Exam”

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TELEHEALTH SERVICESNew Patient Scenario:23 year old patient calls the office to schedule a new patient office visit. Patient is scheduled for new telehealth visit. On the day of the appointment, provider and patient connect through BlueJeans. Provider obtains a verbal consent before proceeding and documents the required attestation for telehealth service. Documentation includes:AttestationChief ComplaintHPI: 4 + elements (location, severity, quality, context, duration, timing , modifying factors, associated signs/symptoms) or Status of 3 chronic conditionsROS: 10+ organ systems; Past Medical (includes medications and allergies), Past Family, Social History (includes smoking, alcohol, living arrangement) Exam: unable to perform or if patient is able to report temperature and blood pressure and you can report general appearance)MDM: Low (no further workup, no prescription, OTC) – LOS = 99213 (no exam, service does not meet new patient requirements)MDM: Low (no further workup, no prescription, OTC) w/one element of exam reported – LOS = 99201 MDM: Moderate (additional workup/orders placed, OTC/RX) w/one element of exam reported – LOS = 99201ADD GT modifier and applicable DX.

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TELEHEALTH SERVICESEstablished Patient Scenario:56 year old established patient calls his provider regarding a new skin rash for the past 3 days. Patient is scheduled for next day established telehealth visit. On the day of the appointment, provider and patient connect through BlueJeans.Provider obtains a verbal consent before proceeding and documents the required attestation for telehealth service.Documentation includes:AttestationChief ComplaintHPI 4 elements (location, timing, duration, modifying factors); obtains 2-9 ROS, PMFSH is not required.Exam: Skin (patient shows provider rash) MDM: Low (no further workup, no prescription, OTC) – LOS = 99213MDM: Moderate (additional workup/orders placed and RX) w/one element of exam reported = LOS 99214ADD GT modifier and applicable DX.

OTHER OPTION: “VIRTUAL CHECK-IN”(Non-Face to Face)

DEFINITION:

A brief communication technology based non face to face service by a physician or other qualified healthcare professional who can report E/M services, provided to an established patient.

TYPE OF SERVICE: A brief medical discussion with the provider (not clinical staff) initiated by an established patient to avoid unnecessary trips to the office

(Practitioners may need to educate patients on the availability of the service prior to patient initiation)

• Communication is not related to a medical visit within the previous 7 days and • Does not lead to a medical visit within the next 24 hours• The patient must verbally consent to receive virtual check-in services• Mode of communication is telephone• Co-pay, coinsurance and deductible would generally apply to these services

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“VIRTUAL CHECK-IN”(Non-Face to Face)

WHO CAN PROVIDE: • Physician• Nurse Practitioner• Physician Assistant• Licensed Midwife

Documentation Requirements:1. Patient consent to a “Virtual Check-In” service2. Start and Stop time .EMTIME

Time (start)***Time (stop) ***

Use Epic smartphrase .attesttelephone to document the attestation.The (***){telehealth relationship:30463} was educated on the use of a telehealth visit in lieu of an in-person evaluation. The (***) {telehealth relationship:30463} has agreed to be evaluated via the telephone at this time.

3. Content of medical discussion

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“VIRTUAL CHECK-IN”(Non-Face to Face)

CPT Codes:

• Prior to date of service 03/31/2020 Medicare - G2012 - 5-10 minutes of medical discussion (United Complete, Medicare Railroad, Aetna Advantage, Clover Advantage also bill as G2012)

• Effective 04/01/2020 Medicare would also be accepting 99441-99443.

• Medicare and Commercial payers including Medicare Advantage and Managed MedicaidØ 99441 – 5 to 10 minutes of medical discussion, not originating from a related E/M service

provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment

Ø 99442 – 11 to 20 minutes of medical discussion, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment

Ø 99443 – 21 + minutes of medical discussion, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment

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“VIRTUAL CHECK-IN”(Non-Face to Face)

Telephone Scenario:

An established patient calls the office with a concern regarding low back pain. Patient was not seen for a related condition in the office within the previous 7 days. The provider needs to obtain verbal consent and document the visit in the telephone encounter.

Documentation includes:

Start Time

Attestation .attesttelephone

Chief Compliant

ROS

Medical Advice

Stop Time

LOS = applicable CPT code based on time (99441-99443; G2012) with applicable diagnosis.

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“VIRTUAL CHECK-IN”(Non-Face to Face)

An established Pediatric patient of yours has been coming in for a variety of illnesses on and off for a few years. The patient was seen about three months ago and six months prior for a urinary tract infection (UTI) and was treated with the antibiotic Cipro successfully. The parent calls today and says that her child is displaying symptoms of another UTI; the parent speaks to the nurse practitioner (NP). Documentation includes:Start Time: 8:58 amAttestation: .attesttelephoneChief Compliant: burning upon urinating, frequency, history of UTIROS: no fever or bedwettingMedical Advice: obtain urine cultures before starting Cipro, RX orderedStop Time: 9:15 am LOS = 99442

Note: It would not be appropriate to bill for the service if the patient was told by the physician to come in at the next available appointment for follow up.

If the patient is seen within 24 hours or the next available urgent visit, this service is bundled into the office visit and consider a pre-service to the office E/M.

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ICD-10 Codes

• COMPLETE AND PRECISE CODING IS IMPERATIVE FOR ACCURATE REPORTING OF COVID-19 CASES

• IDENTIFICATION OF HOT SPOTS AND INFECTIOUS RATES ARE BASED ON YOUR REPORTED ICD-10 CODES

• IMPROPER ICD10 CODING IMPACTS PATIENT COST SHARE. PAYERS HAVE WAIVED COST SHARE FOR TREATMENT OF COVID19

.

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DOCUMENTATION & CODING For COVID-19

• The diagnosis code B34.2, Coronavirus infection, unspecified, would not generally be appropriate for COVID-19 because confirmed cases have universally been respiratory in nature, so the site would not be unspecified.

• According to the new guidelines, do not assign code B97.29 if the documentation states “suspected,” “possible,” or “probable” COVID-19. Instead, assign codes explaining the reason for the encounter (such as fever, or Z20.828).

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Documentation For COVID-19

Documentation must support the ICD10 assigned to the service and

• Confirm a positive test of COVID-19

• Link any associated respiratory conditions

• Identify that the infection was present on admission

• Consistently document comorbidities such as acute respiratory failure, ARDS, COPD exacerbation, PNA, CHF, MI, etc.

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NEW ICD-10 CODE COVID-19 – U07.1

CDC Announcement: Effective April 1, 2020

New ICD-10-CM code for the 2019 Novel Coronavirus (COVID-19)

Due to the urgent need to capture the reporting of COVID-19, the Centers for Disease Control (CDC), under the National Emergencies Act Section 201 and 301, announced a change in the effective date of the new diagnosis code U07.1, COVID-19, from October 1, 2020 to April 1, 2020.

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CODING COVID-19

§ Do not code “suspected’, “possible’, or “probable” COVID-19

§ Assign a code(s) explaining the reason for the encounter

§ Do not use Coronavirus infection, unspecified, for the COVID-19. Cases have universally been respiratory in nature, so the site would be “unspecified.”

§ Presumptive positive – A presumptive positive test is for the time between an initial positive test for the virus by a public health lab but before the federal Centers for Disease Control and Prevention has confirmed the results. A Presumptive positive result from a CDC test is treated as if the patient is positive for the virus, according to the CDC.

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CODING For COVID-19Pneumonia confirmed due to COVID-19

Assign codes: Ø U07.1 - COVID-19.Ø J12.89 - Other Viral pneumoniaØ B97.29 - Other coronavirus as the cause of diseases classified elsewhere.

Acute Bronchitis confirmed due to COVID-19

Assign codes:Ø U07.1 - COVID-19.Ø J20.8 - Acute Bronchitis due to other specified organismsØ B97.29 - Other coronavirus as the cause of diseases classified elsewhere.

Bronchitis not otherwise specified (NOS) due to COVID-19

Assign codes:Ø U07.1 - COVID-19.Ø J40 - Bronchitis, not specified as acute or chronicØ B97.29 - Other coronavirus as the cause of diseases classified elsewhere.

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CODING For COVID-19Acute Respiratory infection, NOS, associated with COVID-19

Assign codes:Ø U07.1 - COVID-19.Ø J22 - Unspecified acute lower respiratory infectionØ B97.29 - Other coronavirus as the cause of diseases classified elsewhere.

COVID-19 associated respiratory infection, NOS

Assign codes:Ø U07.1 - COVID-19.Ø J98.8, Other specified respiratory disordersØ B97.29, Other coronavirus as the cause of diseases classified elsewhere

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CODING For COVID-19 WITH OTHER CONDITIONSAccording to the Interim Clinical Guidance for Management of Patients with confirmed COVID-19,

Acute Respiratory Distress Syndrome (ARDS) may develop.

Cases with ARDS due to COVID-19

Assign codes: Ø U07.1 - COVID-19.Ø J80 - Acute respiratory distress syndromeØ B97.29 - Other coronavirus as the cause of disease classified elsewhere.

https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html

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Coding COVID-19EXPOSURE TO COVID-19

Possible exposure to COVID-19, but ruled out after an evaluation

Assign codes:Ø Z03.818 - Encounter for observation for suspected exposure to other

biological agents rules out.

Actual exposure to someone who is confirmed to have COVID-19

Assign codes:Ø Z20.828 - Contact with and (suspected) exposure to other viral communicable

diseases

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Coding COVID-19Coding scenario 188 year old female presents to ER with granddaughter for failure to thrive. Per granddaughter patient has been very lethargic and weak for last 1 week. Patient is not taking her medications, refusing to eat, sleeping 22 hours a day. Per granddaughter patient is refusing to do anything to get out of bed. In ER patient is awake and alert x 2 with fever chills. Granddaughter states no change in medication. Patient went to PCP today who referred her to ER for admission for dehydration and evaluation for possible COVID-19.

CXR: Hyperinflation compatible with COPD. Will consult pulmonary for further recommendations. Continue to monitor.Smoking status: Former Smoker

Respiratory: Patient with cough, chest tightness and shortness of breathDischarge Summary

Reason for Hospitalization: COVID-19 with PNA and COPD exacerbation

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Coding scenario 1- PneumoniaFor a pneumonia case confirmed as due to the 2019 Novel Coronavirus (COVID-19), assign codes:U07.1 – COVID-19

J12.89 – Other Viral PneumoniaB97.29 – Other Coronavirus as the cause of diseases classified elsewhere

J44.0 – Chronic Obstructive Pulmonary Disease with (acute) lower respiratory infection

J44.1 – Chronic Obstructive Pulmonary Disease with (acute) exacerbation

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Coding scenario 2 – Bronchitis84 year old female who presents to the emergency department with complaint of shortness of breath while walking. She states that she has been coughing over this time as well, and notes she has relatives that recently returned from overseas travel. She admits to fever of 101.5 at home with chills. She denies any chest pain, nausea, sweating, or radiating pain anywhere. In addition, She also notes generalized weakness, and lightheadedness with change of position. Patient with worsening SOB for the past several days. Worsening bronchitis with positive test for COVID-19

Correct Coding – Bronchitis me with chills. She denies any chest pain, nausea, sweating, or In addition, She also notes generalized weakness, and lightheadedness with U07.1 - COVID-19J40 - Bronchitis, not specified as acute or chronicB97.29 - Other Coronavirus as the cause of diseases classified elsewhere

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Coding scenario 3 – Suspected COVID-19

56 year old male who presents to the emergency department with complaint of cough and shortness of breath.

He states that a coworker in his office test positive for COVID-19.

Negative for fever, chills, or chest pain. Admitted for confirmed exposure and suspected COVID-19 with cough

and SOB. Cultures negative.

Correct Coding- Exposure with Signs/Symptoms

R05 - Bronchitis, not specified as acute or chronic

R06.02 - Shortness of breath

Z20.828 - Contact with and (suspected) exposure to other viral communicable diseases

with and (suspected) exposure to other viral communicable diseases

e with chills. She denies any chest pain, nausea, sweating, or In addition, She also notes generalized weakness, and lightheadedness with

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When to Query• When clinical indicators are present (fever, cough, SOB), and only

suspected case is documented.

• When positive lab test is present, but there is not confirmation from the provider.

• When associated respiratory conditions are not specifically linked to a confirmed COVID-19 infection.

• When documentation is inconsistent between physicians.

• When the present on admission status of the infection is unclear.

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Query Examples• Patient presented with fever, cough, SOB. ED report states suspected COVID-19.

Patient treated with antiviral medication. Please clarify the diagnosis as either confirmed COVID-19, still suspected at discharge, clinically unknown, or other diagnosis (please specify).

• Patient presented with SOB and positive COVID-19 lab test is present. Patient treated with antiviral medication. Please clarify the diagnosis associated with the patient’s clinical presentation and treatment.

• Patient presented with Pneumonia in ER and COVID-19 infection confirmed on the discharge summary. Please clarify if the patient’s diagnosis of pneumonia is related or unrelated to COVID-19.

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Query Examples• Patient presented with chest pain, SOB, elevated troponins. Admitted for

suspect MI. Three days after admission, the patient was diagnosed with pneumonia due to COVID-19. Please clarify if the pneumonia and COVID-19 infection were present on admission or developed after admission.

• Attending physician PN indication bronchitis due to COVID-19. Pulmonary consult states COVID-19 infection unlikely, probably related to influenza. Please clarify the diagnosis as either bronchitis due to COVID-19, bronchitis due to influenza, clinically unknown, other diagnosis (please specify).

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HMHCovid.org

The following link is available to find the most updated material regarding Telehealth Services:

HMHCovid.orgSelect - Clinical Protocols & PoliciesScroll down to bottom – Ambulatory Scheduled Video Visits

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QUESTIONS

Contact Coding Quality Educators:

HMMGCoding@hackensackmeridian.org

• Giselle CocaCall: 551-996-2000 ext. 76704Email: Giselle.Coca@hackensackmeridian.org

• Eileen WiedemannCall: 551-996-1830Email: Eileen.Wiedemann@hackensackmeridian.org

• Madeline MercadoCall : 551-996-1926

Email: Madeline.Mercado@hackensackmeridian.org

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