Teledermatology in the COVID-19 era
Cracking the code
Dr. Miller, who is in private practice in Yorba Linda, California, represents the American Academy of Dermatology on the AMA-CPT Advisory Committee.
By Alexander Miller, MD, May 1, 2020
Teledermatology: We may have been considering implementing it in our practices, and then wham! COVID-19 has transformed how we interact with patients and has brought teledermatology to the forefront. Many practices have or are integrating various forms of electronic interactions as part of their response to life with COVID-19.
I suspect that teledermatology will gain patient and physician acceptance, such that once the COVID-19 emergency is over, some patients will continue expecting teledermatology services, including for basic screenings to determine a need for an office visit. We will be wise to prepare for such a paradigm shift in care structure.
During the declared public health emergency (PHE) relating to COVID-19, HIPAA compliance of transmitted data is waived. This facilitates ease of communication with patients via a variety of modalities, including telephone communication, email, text messaging, and real-time video interactions through both encrypted and HIPAA-compliant technology as well as FaceTime, Skype, and other messaging platforms that can restrict the communications to direct interactions between the patient and qualified health care professional. Sites that expose the electronic interactions to the public are to be avoided.
Prior to initiating a telehealth interaction, the following steps are recommended:
Obtain and document consent in the patient record for the telehealth interaction. During the COVID-19 PHE, Medicare announced that the health care professional can obtain an annual consent at the time of the virtual encounter.
Explain that the patient’s insurance (or the patient) will be billed for the service
Verify that the electronic interaction will be private between the patient and physician/qualified health care professional, and is not inadvertently exposing it to the public, such as via Facebook Live or similar platforms
Consider reviewing optimal photo/video techniques with the patient prior to the electronic interaction. Blurry images submitted by patients can stifle diagnostic accuracy.
Various forms of telehealth services are characterized by dedicated billing codes and modifiers. To make concepts somewhat more confusing, Medicare stipulates some codes and billing conventions that may differ from that of private insurers, and private insurers’ billing requirements may vary from insurer to insurer. Below is a synopsis of relevant reporting codes for interactions with patients.
Live interactive (synchronous) audio and video, new or established patient: CPT 99201-99215; may require 95 modifier. Documentation for the virtual encounter must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. Final choice of the level of service can be based on the medical decision making (MDM) OR time.
Virtual check-in: G2012 (Medicare only) – brief 5-10-minute triage encounter to determine if office visit is warranted.
Store and forward (asynchronous) evaluation:
Remote evaluation: G2010 (Medicare only) – of still and/or video images transmitted by an established patient to the physician
E-visits
Medicare and private insurers:99421, 5-10 minutes cumulative time during 7-day period
99422, 11-20 minutes
99423, 21 or more minutes
Telephone evaluation/communication
Medicare (during the COVID-19 PHE) and private insurers:99441, 5-10 minutes discussion
99442, 11-20 minutes
99443, 21-30 minutes
For complete explanations of the nuances of telehealth codes consult the updated Derm Coding Consult publication.
As mentioned, Medicare, private insurers, and individual state policies and mandates governing telehealth interactions as well as coding requirements have been in flux, sometimes changing by the day. Keep current on policy and billing requirements by regularly visiting the Academy’s COVID-19 teledermatology resources. During the COVID-19 PHE Medicare has allowed qualified health care professionals to provide telehealth services from their homes. These services can be reported with place of service (POS) 11 with modifier 95.
Please check directly with the private payers you are contracted with for specific coding and billing guidance because policies may vary from payer to payer and sometimes plan to plan.
Example 1
I have successfully implemented teledermatology into my practice by viewing patients in real time via FaceTime and/or Skype. Now that I know it works, I will permanently integrate this system into my practice.
Answer: Good and bad choice. Teledermatology, once shown to be effective, will very likely persist within our practices. However, the non-HIPAA compliant video transmission modalities are only acceptable during the present declared COVID-19 public health emergency period. Once the emergency is declared over, one would have to use HIPAA-compliant transmission systems. The AAD provides a recurrently updated list of HIPAA compliant telemedicine vendors on its teledermatology website. Some insurers offer select telehealth platforms for patient interactions. However, such systems may not allow for direct interaction with a physician of one’s choice.
Example 2
I practice in California. I am reluctant to offer telehealth services to all of my patients, as I am uncertain whether insurance companies will pay for submitted telehealth charges.
Answer: California agencies regulating health insurers have stipulated that health insurers must provide for telehealth access and are required to reimburse for those services at the same contractual rates as for in-person, face-to-face evaluation and management (E/M) services. Telephone services are also covered and reimbursable. Individual states may vary in their stipulations for telehealth coverage. Check with your state medical society for information. The AAD website offers a frequently updated list of private insurers and their telehealth coverage and reimbursement policies in an Excel download in the COVID-19 Resource Center.
Example 3
I evaluated an established patient’s changing back lesion via a synchronous (live interactive) telehealth modality. The interaction included obtaining a history pertaining to the lesion as well as an evaluation of a multi-angled live video imaging of the lesion. Suspecting a squamous cell carcinoma, I asked the patient to schedule an in-person visit for a biopsy. I submitted CPT 99212-95 for the telehealth service. A punch biopsy done on a subsequent day was reported with CPT 11104, with no E/M visit charge.
Answer: Correct. The relevant E/M evaluation was previously done via the telehealth interaction and was reported as such. No separately distinguishable E/M service was done on the day of the biopsy.
Example 4
Argh! I just completed a synchronous teledermatology visit. How do I calculate the E/M visit level?
Answer: The level of visit (CPT 99201-99215) is determined in the same fashion as for an in-person, face-to-face visit. Typically, the “key components” of E/M, history, examination, and medical decision making are used to complete the documentation. During the COVID-19 PHE, Medicare has allowed physicians to use the medical decision making OR time to determine the appropriate level of E/M. The time components can be viewed within the E/M code descriptors in the CPT coding manual.
Example 5
You evaluate a brief patient history and lesion images sent electronically by an established patient and determine a need for a biopsy. On the same day the patient comes in and has a tangential biopsy done. You report CPT 99421 for the brief online digital evaluation service and 11102 for the tangential biopsy.
Answer: Incorrect. Since the asynchronous (store and forward) digital interaction led to a prompt patient visit related to the evaluation, the online digital evaluation should not be reported. Any provided E/M service not considered to be inherent to the 11102 (tangential biopsy) code would be separately reportable (CPT 99212-99215) appended with modifier 25.
