COVID-19 and the emergency declaration announced by the president in mid-March have led to a number of issues for eye care professionals. These include reduced schedules, loss of income, and the safety of our patients, providers, and fellow staff members.

Your providers will see ocular trauma and emergencies, like angle-closure glaucoma, as usual, and billing will stay the same for these cases. Routine patient visits, though, have been moved into summer. Other patient conditions, wet AMD, for example, are not as emergent, but good medical care means they can’t be delayed more than a week or so. These patients require the usual in-person visit with the doctor, but we might make allowances for social distancing in the reception area. Again, billing and coding are unchanged.

But how should we handle all the other patients? How do we address a patient’s concern when it’s hard to tell whether it is an “urgent” medical condition without seeing the patient?

The answer for how to ensure everyone’s safety while also allowing for proper evaluation for that group may be telemedicine. The term “telemedicine” can mean many things, and payers do not use the term interchangeably with “telehealth.” But don’t fret about the difference in the current COVID-19 era; the rules are considerably relaxed to keep the American population safe.

It is important to know something about telemedicine, including what is possibly billable to insurance, what is not, and how to code it properly.

What can be billed

Services that may be billed and involve technicians break down into three main types: phone calls (audio only), audio/video (live and between the doctor and patient), and internet (email back-and-forth). We could further segregate this into whether this is done “live” or as “store-and-forward.”

Some things remain not payable, including visits and calls related to a postop global period, calls solely to give test results, rescheduling appointments, and other things done by staff alone (eg, insurance verification and prior authorization).

HIPAA and other requirements

Regarding worries about HIPAA and privacy, the requirements for secure platforms, normally in place under Section 1135 of the Social Security Act, would be impossible to implement in this current climate; and the government has stated it will not be enforced during this public health emergency, retroactive to March 1. Medicare and most payers also have relaxed the rules on delivering services, in some cases, only to established patients. For more information, visit cms.gov .

It is important to note that when HHS Secretary Alex Azar declares an end to the emergency, the “non-secure option” and general code requirements (the codes only for use on established patients, for example) will no longer be waived and the looser standards will vanish.

Documentation

Verbal consent is explicitly required in CPT for some telemedicine services, but it is highly recommended for all of these encounters. This helps to avoid acrimony later and preserve a good relationship with the patient. A verbal acknowledgment provides: consent to being seen this way; allowance to bill their insurance or bill patient. It’s particularly warranted in those instances when the telemedicine service is not covered.

The extent of the chart documentation will vary, but it is particularly important to note the time devoted to the service by the provider. Please note that some of the codes are serial online services that might occur over a week, and the time is cumulative. Thus, good documentation of this is important.

Coding

Most codes we use are CPT codes, but there is another relevant code set: Healthcare Common Procedure Coding System (HCPCS). The American Medical Association is responsible for CPT, and the Centers for Medicare & Medicaid Services (CMS) is responsible for HCPCS. While they overlap some, each code set has codes that are unique.

The Table shows the telemedicine codes we might encounter. The short descriptor in the table does not show the entire CPT or HCPCS code, so check the respective longer description to ensure it is met. Additionally, higher level codes are likely to be more emergent and the patient will be seen physically, not via telemedicine, so they are omitted here.

Most often, when we see patients in the office, we use eye and evaluation and management E/M codes for eye exams. That means we review the chart, add a history, perform tests, develop a management plan, and sometimes write prescriptions or recommend surgery. Then, we explain it to the patient. Only E/M eye exam codes (992xx) meet this criteria under telemedicine. Exams can still happen in telemedicine, but we are not physically face-to-face with our patients — it happens “virtually.” Eye codes (920xx) exam codes do not qualify for telemedicine. These must occur with live audio and video — speaking on the phone is not enough.

Here, technicians can be involved just like in the office — they can take the history and get a visual acuity. In this case, it won’t be like a normal one — in this case, it is sufficient to ask the patient to read something and note the distance. For example, you could record “reads newspaper print at 10 inches OD and 6 inches OS.”

Then, the doctor can perform a physical exam that only includes elements that can be done adequately via video conference. This will be limited but can include cornea, eyelids, conjunctiva/sclera, and iris/pupil as well as extraocular muscles, if possible. Fundoscopy, confrontation visual fields and IOP are not likely to be possible in the virtual exam.

As a result of the fewer exam elements, if the patient is established and the level of decision-making is either low or moderate, CPT 99213 is likely supported. If it turns out to be more straightforward decision-making, then code as 99212. New patient exams are possible, but likewise limited in terms of level. Remember to use POS 11 and modifier 95 on claims as noted in the Table.

Voice-only phone calls (see G2012 and 9944x codes in the Table) may also be reimbursed, but only for the provider time spent on the phone with the patient. Be sure the provider records the time to ensure compliance and proper code selection. As above, it is important to document consent for the service and billing in the chart note.

The last of the common options for telemedicine is the “online service.” These exams are initiated by patients through a secure portal. The HIPAA “secure platform” requirement for the 9942x codes in the Table is waived during the COVID-19 emergency. We believe use of these codes will be less common than the G codes or even the virtual E/M exam codes.

These 9942x codes can be cumbersome to track. Instead of a phone call, or after the tech triages a call as fairly straightforward, you could ask the patient to reach out to you via patient portal for a “patient-initiated” telehealth service. They should consent, as noted, and this should be recorded in the chart.

One telehealth service may be billed in a 7-day period, even if multiple back-and-forth communications take place. Track the time the doctor and patient spend over the 7-day period, and bill the appropriate code (CPT 99421, 99422, or 99423). Note, technicians cannot do this all by themselves — the provider must be involved.

Modifiers for telemedicine

Modifiers present another coding challenge, and not all payers agree on usage. Within CPT, modifier 95 is used to designate telemedicine for eligible services, those marked with a ★ in the manual. Medicare has a couple of longstanding modifiers for telemedicine (GT [synchronous communication] and GQ [asynchronous communication]) but has decided during the crisis that only modifier 95 should be used. It is likely, but unclear whether other payers will follow. In addition, do not apply the “disaster” and “catastrophe” waiver modifiers DR and CR.

Place of service

CMS’ place of service code for telehealth is normally “02” which signifies telehealth (the patient and the doctor are not physically in the same place). On March 30, CMS advised that telemedicine services should use place of service “11,” which is the same one we have used all along. That means payment will be at the normal office rate, instead of a reduced rate. This was done to help offices offset some of the big losses of revenue.

The future

I personally believe the “genie is out of the bottle” and we will all have to get used to telemedicine, even if the regulations are tightened after the emergency. While it won’t work for everything, we will get more comfortable with it. It is also likely that some of the services we are not able to provide virtually right now, will become possible later. It’s too bad it has taken an emergency of this sort to show us what is possible.

Summary

We can still “see” our patients and deliver care. Telemedicine will be a valuable tool to “bridge the gap” during the COVID-19 public health emergency until we all get back to our normal operations. Some calls and visits can be billed while others cannot, and it is important to understand where the lines are drawn.

Be safe. Protect yourselves and your patients. And as always, “good coding to you.” OP