Tap into Telehealth Q&A Transcripts

Have you heard if WhatsApp is allowed?

At this time, we do not know if WhatsApp is allowed. We would suggest that you reach out the WhatsApp vendor or reach out to your regional Medicare rep to learn if WhatsApp is allowed.  (Subsequent to the webinar, the Office of Civil Rights’ Frequently Asked Questions (#10) stated that WhatsApp is acceptable: https://www.hhs.gov/sites/default/files/telehealth-faqs-508.pdf )

We've consistently been dropping videos that are freezing, forcing us to complete the rest of the visit by audio telephone, not via telehealth. Has this provision been made for telephonic-only telemedicine? Another question similarly related, does the provider need to be at his or her office or can this be done from home?

First, we suggest you work with your IT staff to improve your connectivity and fewer videos are dropped. That said, if you start the visit via the web using audio/visual and the video portion is dropped but you complete it, we don't think you're going to get penalized because you made every reasonable attempt and indeed did connect – at least initially.  If you were unable to connect using video for any portion of the visit, the visit cannot be billed as telehealth but could be billed as G2012 (telephone communication).

Based on current Medicare language, you should have audio and visual capabilities to be able to bill a telehealth visit. If it's purely telephonic, you've started the visit that way, then following the CMS guidelines you probably should not bill a telehealth visit. If you have additional questions or concerns you should consult with your regional Medicare provider. 

Can a provider do telehealth from home?
Technically, Medicare language states that the provider needs to register his/her home address as an additional site for CMS coverage. However, you may not want your home address released to every patient in your practice. There is probably some flexibility in doing that, but in the purest sense from CMS, it says register your address.

A lot of LUPGA practices are connecting everything through a VPN, through TeamViewer or some other application running everything through the main practice site. This would justify doing the visits at home without registering your home address.  But this is new world, uncharted territory, and you should seek your own advice and your own comfort level for what you're doing.

Once again, they've made a very important point to say you don't have to have the established relationship. You do historically but they're not going to audit it, implying that they're allowing new patients to be seen. We think a similar accommodation is probably going to be made from these visits from home, especially as more states get on lockdown.

Do I have to state the reason for the virtual visit?

Yes, CMS requires that you state it. We believe that CMS still wants the documentation to show whether the patient is sitting in front of you or remotely. We would argue that it's important to be able to tie it back to this crisis so that in the future if there were any type of a malpractice or professional liability claim you actually would have the regulations from CMS as a validating reason.

Does this mean that we can build new patient codes? Or can you bill a new tele-visit as an established code without fear of audit?

We're not in the position to give legal advice.  CMS made it very clear in their FAQs that they are not going to audit to confirm that an established relationship existed at the time of the telehealth visit.  However, they did not include new patients as a payable category or make any reference to a patient relationship outside of the “established” patient definition.

Outside of the CMS regulations, providers still must meet the basic requirements of the CPT code for which they are billing.  The FAQ helped resolve some underlying questions, so bill as you're doing following the appropriate coding guidelines.

CAUTION: You still must meet the level requirements of your CPT codes. If you're not doing the physical exam for those upper level codes you've really got to make sure that you've got that time documented clearly and that you've got some type of a conversation that's documented around review of systems and all the normal elements that you would have with a new patient visit since you're not going to be able to prove that you did a physical exam.

You described the 7-day global for the same problem. If this Pandemic runs out to 3-4 months which is predicted, can we use telehealth for 3-month follow up visits on problems such as stones or BPH?

The seven-day global period was for those e-visits and telephone encounters. You can see the patient in follow-up for a problem like BPH via telehealth within 30 days if they're still having issues. You can use the same billing and coding parameters that you've used previously.

Can you bill a 99213 with video assessment? Since only 2/3 elements are needed, could you exclude a physical exam.

We think you could if you are documenting appropriately. Some practices are choosing to avoid new patients visits right now – not because of practice ability or audits. If the claim gets rejected, do you have any appeal rights? If you file the claim, something happens and it gets rejected, can you appeal when, in fact, you didn't meet the requirements?

Many groups are using those codes for new patients and, if you feel comfortable clinically and you can treat that patient appropriately, then it’s fine. You must understand you may be forfeiting the payment on that visit, but it does need to be documented – that cannot be stressed enough. Most of the commercial carriers are following the CMS lead so documentation is king. Document everything under the CMS guidelines.

If you have an in-house lab can you integrate that with telehealth for established patients?

You may choose to keep your lab open to keep the ancillaries up and going. For a urology practice, the biggest issue is how does your practice deal with dropping off urines for UTIs?  Most don't permit it. However, in a situation like this there is very little choice but to permit it and still run it through your in-house lab, thus treating lab work the same as we would if the patient were sitting there. They may have to drop a urine off but that doesn't mean that they must have an in-person office visit during the crisis.

What are you using for your telehealth activities?

Zoom is good, but there are many other good, valid carriers. We don’t advertise any particular one.

Can billing be retroactively applied for tele-visits or patient calls?

We advise caution here. Given the rapid changes in legislation, we would not go back further for doing that unless you've documented it previously and have the visit in writing.

We have found different effective dates for commercial carriers so we would caution using March 6th (coincides with the 1135 waiver) for anything other than Medicare without checking the individual policy first.  Most carriers - United Health, Cigna, Aetna, Blue Cross - are specifying an effective date and most of those effective dates are at least a week or two after the March 6th Medicare date.

Phone calls and billing.

Medicare will pay for the G codes G2012 and G2010s, but a lot of the private payers will pay for the 99411, 99442, 99443, from five to 10 minutes, 11 to 20 minutes, and 21 to 30 minutes, respectively. You can bill for those phone calls should the patient not have the ability or want to do an interactive visit.

Do I need to get a separate work computer and phone? Will my employer need to cover my internet and phone access?

Those are questions probably better reserved for your legal counsel and tax advisors in your state.  Certainly, you need to be careful if you're using any personal devices with respect to the HIPAA laws, so please also refer to your legal counsel here.

What about using FaceTime?

With FaceTime, you cannot block your both your email address and phone number. Patients will have access to a provider’s information. It’s likely your physicians/providers will not be comfortable with this.

Isn't visual inspection by screen consistent with large portions of the physical exam for documentation?

The answer to that is clearly, “Yes.” There are several exams that can be documented by visual inspection without physically laying a hand on the patient and does qualify - normal respiratory excursions, appearance of skin, et cetera.

Those things can be documented on the services and indeed have been described elsewhere in previous coding documentation courses. You can get seven or eight, even up to nine physical exam bullet points on a visual inspection and so that could meet some of the requirements.

Are you using G codes and then making established patients from new patients? Can we use that methodology?

If you decide to bill new patients and you bill that new patient code - even with place of service included -  you need to make sure you're not billing a new patient visit on the next visit that the patient actually has either by telehealth or in person. A contact is a contact, so once you establish that relationship, it's established and won't be broken per CPT for three years. Make sure you didn't bill a new patient on telehealth and then turn around and bill a new patient when they first come into the office physically.

Is your practice doing CT scans?

This is what Urology San Antonio is doing:

We have canceled all elective procedures in the ASC and at the hospital. We are continuing to do cystoscopies because we still need to be able to take care of those patients. (Note: Shortly after the presentation, the Texas Medical Board further restricted procedures, so the group is no longer performing cystoscopies.)  Certainly, with some of our stone patients, those patients can't wait for that so there are instances where some procedures are medically emergent.

We've classified patients into four separate surgical tiers, and we're coordinating the local hospital systems to make sure that we're staying aligned with what they're wanting and with state guidelines. Again, they don't want these patients coming into the ER or into the hospital so we're making sure that we're just aligned with them. We are still doing CT scans, basic procedures that we normally do in the office, lab work and things like that, we are still doing those. We're continuing because these patients still need to have care.

Per Mike Fabrizio - I think doing these from home is definitely feasible and it's certainly in many states now patients are being quarantined and you're having to stand down and not travel; home visits are allowed. CMS, as we said, has relaxed that way to register. Stay tuned for the next three months as to what we can do.

Billing only for time

Yes, you can bill for time. It's very important to put on the code as the example of one of the slides noted. You can use the same components as you do in the office to bill for those encounters.