Article - Billing Scenarios during COVID-19 Public Health Emergency

The Centers for Medicare & Medicaid Services (CMS) lifted Medicare restrictions on the use of telehealth services during the COVID-19 emergency.

Key changes include:

· Effective March 6, 2020 and throughout the national public health emergency, Medicare will pay physicians for telehealth services at the same rate as in-person visits for all diagnoses, not just services related to COVID-19.

· Patients can receive telehealth services in all areas of the country and in all settings, including at their home.

· CMS will not enforce a requirement that patients have an established relationship with the physician providing telehealth.

· Physicians can reduce or waive cost-sharing for telehealth visits.

· Physicians licensed in one state can provide services to Medicare beneficiaries in another state. State licensure laws still apply

Scenario 1:

Patient comes to office for E/M visit, is tested for COVID-19 during the visit

Action

In-office E/M visit

Patient swab sample collected

COVID-19 test performed

Who is performing

Physician/QHP

Clinical staff (e.g., RN/LPN/MA)

Laboratory

Applicable CPT Codes

99201-99205 (New Patient)
99212-99215 (Established Patient)

Included in E/M

87635: Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique

Applicable ICD-10 codes

Possible exposure to COVID-19 Z03.818
Actual exposure to COVID-19 Z20.828

   

   

Place of Service (POS)

11 Physician Office

   

11 Physician office
19 Off Campus Outpatient Hospital
22 On Campus Outpatient Hospital
81 Independent Laboratory

Scenario 2:

Patient comes to office for E/M visit re: COVID-19 and is directed to a testing site

Action

In-office E/M visit

Patient swab sample collected

COVID-19 test performed

Who is performing

Physician/QHP

Testing Site

Laboratory

Applicable CPT Codes

99201-99205 (New Patient)
99212-99215 (Established Patient)

99001: Handling and/or conveyance of specimen for transfer from the patient in other than an office to a laboratory (distance may be indicated)

87635: Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique

Applicable ICD-10 codes

Possible exposure to COVID-19 Z03.818
Actual exposure to COVID-19 Z20.828

   

   

Place of Service (POS)

11 Physician Office

15 Mobile Unit
17 Walk-in Retail Health Clinic
20 Urgent Care Facility
23 Emergency Room Hospital

11 Physician office
19 Off Campus Outpatient Hospital
22 On Campus Outpatient Hospital
81 Independent Laboratory

Scenario 3:

Patient received telehealth visit re: COVID-19, and is directed to come to physician office or physician’s group practice site for testing

Action

Patient evaluated for COVID-19 testing need: E/M telehealth OR
telephone visit (Flexibility: permit audio only for E/M Telehealth)

Pt goes to office

Throat swabs taken in office

COVID-19 test performed

Who is performing

Physician/QHP

 

Clinical Staff (e.g., RN/LPN/MA)

Laboratory team

Applicable CPT Codes

New Patient: E/M Telehealth: 99201/99202/99203/99204/99205

Established Patient: E/M Telehealth OR Telephone Evaluation (independent of E/M):
99212 (typical time 10 min)
99213 (typical time 15 min)
99214 (typical time 25 min)
99215 (typical time 40 min)

99441 (5-10 min)

99442 (11-20 min)

99443 (21-30 min)

Patient directed to proceed to office for COVID-19 testing

99211

87635: Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique

Applicable ICD-10 codes

Possible exposure to COVID-19 Z03.818
Actual exposure to COVID-19 Z20.828

   

   

   

Place of Service (POS)

02 Telehealth

 

   

11 Physician Office

11 Physician office
19 Off Campus Outpatient Hospital
22 On Campus Outpatient Hospital
81 Independent Laboratory

 

Note: Payers may require the use of Modifier 95 for telehealth services and add modifier 25 if same date of service as Physician/QHP assessment.

Scenario 4:

Patient received telehealth visit re: COVID-19, and is directed to unaffiliated testing site

Action

Patient evaluated for COVID-19 testing need: E/M telehealth OR
telephone visit (Flexibility: permit audio only for E/M Telehealth)

Pt goes to testing site

Throat swabs taken at remote testing site, delivered to lab

Coronavirus test performed

Who is performing

Physician/QHP

 

Testing Site

Laboratory team

Applicable CPT Codes

New Patient: E/M Telehealth: 99201/99202/99203/99204/99205

Established Patient: E/M Telehealth OR Telephone Evaluation (independent of E/M):
99212 (typical time 10 min)
99213 (typical time 15 min)
99214 (typical time 25 min)
99215 (typical time 40 min)

99441 (5-10 min)

99442 (11-20 min)

99443 (21-30 min)

 

99001: Handling and/or conveyance of specimen for transfer from the patient in other than an office to a laboratory (distance may be indicated)

87635: Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique

Applicable ICD-10 codes

Possible exposure to COVID-19 Z03.818
Actual exposure to COVID-19 Z20.828

 

N/A

N/A

Place of Service (POS)

02 Telehealth

 

15 Mobile Unit
17 Walk-in Retail Health Clinic
20 Urgent Care Facility
23 Emergency Room Hospital

11 Physician office
19 Off Campus Outpatient Hospital
22 On Campus Outpatient Hospital
81 Independent Laboratory

 

Note: Payers may require the use of Modifier 95 for telehealth services

Scenario 5:

Patient receives virtual check-in/online visit re: COVID-19 (not related to E/M visit), and is directed to come to physician office for testing

Action

Patient evaluated for COVID-19 testing need: Online digital E/M

Pt goes to office

Throat swab taken in office

COVID-19 test performed

Who is performing

Physician/QHP

 

Clinical Staff (e.g. RN/LPN/MA)

Laboratory team

Applicable CPT Codes

New Patient: N/A

Established Patient:
99421 (5-10 min)
99422 (11-20 min)
99423 (21 or more min)

G2010 Remote Image
G2012 Virtual Check-In

Patient directed to proceed to office for COVID19 testing

99211

87635: Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique

Applicable ICD-10 codes

Possible exposure to COVID-19 Z03.818
Actual exposure to COVID-19 Z20.828

 

 

 

Place of Service (POS)

11 Physician Office

 

11 Physician Office

11 Physician office
19 Off Campus Outpatient Hospital
22 On Campus Outpatient Hospital
81 Independent Laboratory

 

Note: Add modifier 25 if same date of service as Physician/QHP assessment.

Scenario 6:

Patient receives virtual check-in/online visit re: COVID-19 (not related to E/M visit) and is directed to unaffiliated testing site

Action

Patient evaluated for COVID-19 testing need: Online digital E/M

Pt goes to testing site

Throat swab taken at testing site, delivered to lab

COVID-19 test performed

Who is performing

Physician/QHP

 

Testing Site

Laboratory team

Applicable CPT Codes

New Patient: N/A

Established Patient:
99421 (5-10 min)
99422 (11-20 min)
99423 (21 or more min)

G2010 Remote Image
G2012 Virtual Check-In

 

99001: Handling and/or conveyance of specimen for transfer from the patient in other than an office to a laboratory (distance may be indicated)

87635: Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique

Applicable ICD-10 codes

Possible exposure to COVID-19 Z03.818
Actual exposure to COVID-19 Z20.828

 

 

 

Place of Service (POS)

11 Physician Office

 

15 Mobile Unit
17 Walk-in Retail Health Clinic
20 Urgent Care Facility
23 Emergency Room Hospital

11 Physician office
19 Off Campus Outpatient Hospital
22 On Campus Outpatient Hospital
81 Independent Laboratory

Scenario 7:

Telehealth visit for a COVID-19 diagnosed patient

Action

Communication method

Patient assessed: E/M telehealth, telephone assessment (Flexibility: permit audio only for E/M telehealth)

Who is performing

 

Physician/QHP

Applicable CPT Codes

Audio or Audio/Video

New Patient: E/M Telehealth:
99201/99202/99203/99204/99205

Established Patient: E/M Telehealth OR Telephone Evaluation (independent of E/M):
99212 (typical time 10 min)
99213 (typical time 15 min)
99214 (typical time 25 min)
99215 (typical time 40 min)
99441 (5-10 min)
99442 (11-20 min)
99443 (21-30 min)

Applicable ICD-10 codes

 

U07.1, COVID-19
Effective April 1, 2020

Place of Service (POS)

 

02 Telehealth

 

Note: Payers may require the use of Modifier 95 for telehealth services.

Scenario 8:

Patient with COVID-19 receives virtual check-in OR on-line visits via patient portal/e-mail (not related to E/M visit) OR telephone call from qualified nonphysician (those who may not report E/M)

Action

Communication method

Patient evaluated

 

Who is performing

 

Physician / QHP

Qualified non-physician (may not report E/M)

Applicable CPT Codes

Virtual Check-In Other Phone Call

G2010 Remote Image
G2012 Virtual Check-In

98966 (5-10 min)
98967 (11-20 min)
98968 (21-30 min)

 

Online Visits
(e.g. EHR portal, secure email; allowed digital communication)

99421 (5-10 min)
99422 (11-20 min)
99423 (21 or more min)

98970/G2061 (5-10 min)
98971/G2062 (11-20 min)
98972/G2063 (21 or more min)

Applicable ICD-10 codes

 

U07.1, COVID-19
Effective April 1, 2020

 

Place of Service (POS)

 

11 Physician Office or other applicable site of the practitioner’s normal office location

11 Physician Office or other applicable site of the practitioner’s normal office location

Scenario 9:

Physician orders remote physiologic monitoring following patient quarantined at home after receiving COVID-19 diagnosis

 

Action

Patient receives initial set-up of monitoring device and education on its use

 

Remote physiologic monitoring treatment management services (First 20 minutes)

Remote physiologic monitoring treatment management services (Each additional 20 minutes)

 

Collection and interpretation of physiologic data digitally stored and/or transmitted by the patient to physician/QHP (Minimum of 30 minutes)

Who is performing

Physician/QHP/Clinical Staff

 

Physician/QHP

Physician/QHP

 

Physician/QHP

Applicable CPT Code(s)

99453: Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment

+

99457: Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes

99458: Remote physiologic monitoring treatment management services, clinical staff/physician/ other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; each additional 20 minutes (List separately in addition to code for primary procedure)

OR

99091: Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/ regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days

Place of Service

11 Physician Office

 

11 Physician Office

11 Physician Office

 

11 Physician Office

Notes

Do not report 99453 for monitoring of less than 16 day

 

Bill once per calendar month, regardless of number of parameters monitored

Use 99458 in conjunction with 99457

 

Bill once per 30 days
Do not report in conjunction with 99457 or 99458

 

 Scenario 10:

(Non-COVID-19 case) Telehealth visit for a non-COVID-19 patient

Action

Communication method

Patient assessed: E/M telehealth, telephone assessment (Flexibility: permit audio only for E/M telehealth)

Who is performing

 

Physician/QHP

Applicable CPT Codes

Audio or Audio/Video

New Patient: E/M Telehealth:
99201/99202/99203/99204/99205

Established Patient: E/M Telehealth OR Telephone Evaluation (independent of E/M):
99212 (typical time 10 min)
99213 (typical time 15 min)
99214 (typical time 25 min)
99215 (typical time 40 min)
99441 (5-10 min)
99442 (11-20 min)
99443 (21-30 min)

Applicable ICD-10 codes

 

Report relevant ICD-10 code(s) related to reason for call or online interaction

Place of Service (POS)

 

02 Telehealth

 

Note: Payers may require the use of Modifier 95 for telehealth services.

Scenario 11:

(Non-COVID-19 case) Patient receives virtual check-in OR on-line visits via patient portal/e-mail (not related to E/M visit) OR telephone call from qualified nonphysician (those who may not report E/M)

Action

Communication method

Patient evaluated

 

Who is performing

 

Physician / QHP

Qualified non-physician (may not report E/M)

Applicable CPT Codes

Virtual Check-In Other Phone Call

G2010 Remote Image
G2012 Virtual Check-In

98966 (5-10 min)
98967 (11-20 min)
98968 (21-30 min)

 

Online Visits
(e.g. EHR portal, secure email; allowed digital communication)

99421 (5-10 min)
99422 (11-20 min)
99423 (21 or more min)

98970/G2061 (5-10 min)
98971/G2062 (11-20 min)
98972/G2063 (21 or more min)

Applicable ICD-10 codes

 

Report relevant ICD-10 code related to reason for call or online interaction

 

Place of Service (POS)

 

11 Physician Office or other applicable site of the practitioner’s normal office location

11 Physician Office or other applicable site of the practitioner’s normal office location

 

This COVID-19 resource from the Medical Billers and Coders (MBC) provides an up to date summary of telehealth rules, including state licensure and private payer policies regarding telehealth coverage. The federal government is requesting private payers to cover telehealth for COVID-19 as a way to minimize the spread of the virus in the community and clinical settings.  Please note that changes in payer policies are changing from day to day, so be sure and check the policies of your practice’s most common payers.


Published By - Medical Billers and Coders
Published Date - Apr-01-2020 Back

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