CMS clarifies telehealth and telephone coding during COVID-19 public health emergency

On April 30, 2020 a second round of expansive changes to telehealth coding as well as regulatory revisions was announced by CMS. These changes were to ensure access to care and flexibility to the healthcare system during the COVID-19 public health emergency (PHE). These recent changes and more can be found in CMS’s Interim Final Rule #5531 (IFC) .

Telephone evaluation and management (E/M) services

CMS has clarified that telephone (audio-only) E/M service codes 99441, 99442, and 99443 can be reported when the patient is unable to use two-way, audio and video technology. These codes will be reimbursed at the same Medicare Physician Fee Schedule (MPFS) rate as established patient E/M codes 99212, 99213, and 99214 respectively. This is being done to provide additional flexibilities for beneficiaries and physicians to reduce exposure risks associated with the COVID-19 pandemic.

The rates in the table below are based on the national MPFS. Please check your local MPFS for the exact reimbursement rate in your locality.

Private payer coverage and coding guidance for telehealth and telephone services can vary from payer to payer and sometimes plan to plan. The AAD/A is proactively tracking payer guidance and has gathered a list of more than 70 updates from private payers (clicking this link will open a downloadable spreadsheet). Please check this resource frequently as it is updated often as more information becomes available.

Time clarified by CMS

Additionally, CMS has clarified that the selection of an E/M service level (99201 – 99215) when provided via telehealth, can be based on medical decision making (MDM) or time.

Time is defined as all of the time associated with the E/M service on the day of the encounter. Medical record documentation must also include a medically appropriate history and/or examination, even though these are not considered in determining the final level of service reported. This policy is similar to the anticipated changes to E/M coding beginning in 2021.

Time is counted based on the total time spent with the patient, including pre- and post-time on the date of service. CMS has also clarified that the typical times for purposes of E/M level selection are the times listed in the CPT code descriptor.

2020 CPT E/M Typical Times

FAQs

Q1: The dermatologist spends 11 minutes speaking with a patient on the telephone regarding a rapidly growing lesion on the forearm. The patient has a history of non-melanoma skin cancers. Based on the lesion’s description and its rapid growth, the dermatologist suspects a squamous cell carcinoma and recommends an in-office biopsy for the following day.

Can the telephone encounter and the biopsy on the subsequent day be reported?

A1: Based on the question above, the telephone encounter cannot be reported. Coding guidelines state in part that if the telephone conversation leads to an appointment within the next 24 hours (or first available appointment), the telephone code cannot be reported separately.

The telephone discussion with the patient would be incorporated in the E/M service that might be reported on the date the biopsy is performed, when a separate and distinct E/M is performed.

Q2: A patient calls the dermatologist worried about a potential flare of her rash. The rash was previously controlled with a topical cream. The dermatologist spends 24 minutes speaking with the patient on the telephone and confirms an exacerbation of the rash. Prescription is ordered to the pharmacy to help control the eruption. How would this encounter best be reported based on time?

A2: This encounter would be reported with telephone E/M code 99443: 21 – 30 minutes based on the time spent evaluating and ordering the prescription for the patient.

Q3: How can I determine when to report an established patient E/M code 99213 based on time during the COVID-19 PHE?

A3: The typical time spent with the patient that is listed for E/M code 99213 in the CPT coding manual is 15 minutes. To determine the total time in the PHE context, calculate the time spent before and after the physician/patient interaction on the day of the encounter, for example, 2 minutes reviewing patient images, 8 minutes interacting with the patient and addressing the patient problem, 6 minutes writing the prescription or speaking/coordinating care with collaborating physician or non-physician clinician for a total time of 16 minutes supporting the reporting of 99213.