Technology-based encounters in dermatology

By Alexander Miller, MD, August 1, 2019

Up until January 2019, Medicare limited reimbursement for telehealth medical services to those delivered in Alaska or Hawaii, a rural Health Professional Shortage Area (HPSA), Federally Qualified Health Center (FQHC), or telemedicine demonstration areas. Recognizing the expansion of store-and-forward technology and the value of these services to their beneficiaries, the Centers for Medicare and Medicaid Services (CMS) introduced two new reimbursable G-codes specifying patient to physician/qualified health professional store-and-forward technology-facilitated, and electronically enabled live interaction communications care.

As detailed in last month’s Cracking the Code column, the Current Procedural Terminology (CPT^®) contains codes for electronically facilitated interprofessional consultation services, and Medicare reimburses for these services when they are medically reasonable and necessary. CPT code 99441 describes reporting of 5-10 minutes of telephone evaluation and management (E/M) services. However, broader codes specifying store-and-forward (asynchronous) and electronic patient with qualified health professional E/M interactions are absent. In its Final Rule for 2019, CMS introduced a new store-and-forward (asynchronous) care G-code and a live interaction code, both reimbursable by Medicare, as defined below.

G2010 – Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous seven days, nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.

G2012 – Brief communication technology-based service (e.g., virtual check-in) by a physician or other qualified health care professional who can report E/M services, provided to an established patient, not originating from a related E/M service provided within the previous seven days, nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.

G2010 may be reported to your Medicare Administrative Contractor (MAC) when you, the physician, or other qualified health care professional (QHP) evaluate information transmitted to you electronically by the patient. This pre-recorded information, consisting of still images or video, must be reviewed, and the patient must be contacted with a follow-up non-face-to-face interaction within 24 business hours after the review. All manner of available electronic follow-up is allowed, including telephone, live audio-video, email, secure text messaging, and secure patient portal. Naturally, both the original image evaluation and the subsequent electronic follow-up should be documented in the patient record. Patient consent to the electronic interaction should be obtained and documented.

There are specified qualifications for billing G2010: There should not be a related E/M service within the preceding seven days, and the remote interaction must not result in a subsequent in-person E/M visit or procedure within the following 24 hours “or soonest available appointment.” The latter, for practical purposes, implies that if a procedure or E/M visit ensues consequent to the store-and-forward interaction, the electronic interaction is not billable. Regarding billing, ensure that your electronic transaction is billed with Place of Service (POS) code 02 Telehealth, as this specifies the delivery of telehealth services from a remote site.

Medicare defines QHPs who may report/bill for electronic patient interactions as those who are allowed to independently bill Medicare for E/M services, including those listed below (source: MLN booklet, Telehealth Services). State laws governing scope of practice and independent billing will also dictate who would be allowed to bill, and under what circumstances or limitations. For Medicare purposes, the following are considered qualified health care professionals:

• Physicians
• Nurse practitioners
• Physician assistants
• Nurse midwives
• Clinical nurse specialists
• Certified registered nurse anesthetists

Example 1: Your established Medicare patient – whom you have not seen face-to-face for two months – sends you electronically transmitted photos of a groin rash. You determine that the images closely resemble a tinea cruris eruption treated by you several months ago. You recommend a topical antifungal agent. Seeing no improvement after two weeks, the patient calls your group practice and schedules the first available appointment with another dermatologist in your group practice. This dermatologist evaluates the patient and prescribes an oral antifungal.

You bill Medicare: G2010 for the initial electronic evaluation

Your associate dermatologist bills: CPT 99212 for the tinea cruris diagnosis and treatment

Answer: Incorrect. Since the patient is seen by another physician of your specialty in your group practice, this would be considered a follow-up visit pursuant to the telehealth evaluation. The subsequent E/M visit would be bundled into the telehealth evaluation and is not separately billable.

Example 2: You evaluate photos of a “suspicious spot” sent to you by your patient. You determine that the lesion may represent an aggressive squamous cell carcinoma and refer your patient to a Mohs surgeon colleague for diagnostic biopsy and potential surgery. The patient makes the first available appointment with the referred dermatologist. You bill Medicare G2010 for your service.

Answer: Correct. Although the electronic interaction led to a subsequent E/M visit, that evaluation was done by an independent physician in a different practice from yours. The G2010 definition states that it should not be billed if the electronic evaluation results in a subsequent E/M visit or procedure provided by the same physician, or another physician within the same group practice, who provided the communication technology encounter.

Example 3: Your established patient, whom you have last evaluated in-person three weeks ago, sends you an image of a rash, concerned that it may be shingles. The photos, despite excellent autofocus capabilities of the patient’s cell phone camera, are quite blurry. You evaluate the photos, speak directly to the patient by telephone to elicit more information, and recommend that the patient send better photos, as you cannot render a precise recommendation based upon the submitted images. You bill Medicare G2010 for the service.

Answer: Incorrect. Since a recommendation beyond that of “send better photos” could not be rendered, a complete electronic evaluation was not done. The service is not billable.

Example 4: A patient has a melanoma widely excised from their cheek. Five days later, the patient returns for suture removal, at which time the dermatologic surgeon discusses the pathology results with the patient and schedules a subsequent melanoma surveillance appointment. Three days after, the patient — concerned about a possible infection — sends the surgeon photos of the surgical site. The physician evaluates the photos and determines a diagnosis and plan. As the electronic encounter occurs more than seven days after the surgery. G2010 is billed to Medicare for the telehealth interaction.

Answer: Incorrect. Although the telehealth service was done eight days after surgery, there was a subsequent physician interaction with the patient that occurred three days prior to the electronic interaction. This included removing the sutures, evaluating the surgical site, counseling the patient about the excision pathology, and determining an appropriate follow-up visit. Consequently, the electronic encounter is not separately reportable.

Example 5: Two weeks after prescribing a topical steroid therapy and skin care regimen for a patient with severe asteatotic eczema, the patient calls the dermatologist using video conferencing to report response to therapy and to ask questions. The QHP obtains and charts a patient consent for the interaction and then immediately activates a timer to track the period spent conversing with the patient. Seven minutes tick by during the interaction, which included discussing response to therapy, answering patient questions, and counseling the patient on further skin care. The service is reported to the MAC with G2012.

Answer: Correct. The brief check-in service originated from a previous E/M service done more than seven days prior to the communication technology contact. The patient consented to the interaction. No subsequent face-to-face visit resulted. This electronic encounter is separately billable.

Example 6: Your patient calls 10 days after surgery and speaks to your licensed vocational nurse to inquire about healing progress and discuss physician-recommended further postoperative care and follow-up. The interaction takes six minutes. G2012 is billed for the service.

Answer: Incorrect. The communication technology-based service was done by a non-physician/QHP. The service provider must be a physician/QHP in order to justify billing G2012. 

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