Coding & Documentation for Telehealth in the ED

12/16/2020

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Coding & Documentation for Telehealth in the ED

TODD THOMAS, CPC, CCS-P

DON H POWELL, DO, FACEP

Telehealth in the ED

Telehealth requires “Interactive telecommunications system that includes, at a minimum, audio and video

equipment permitting two-way, real-time interactive communication between the patient and distant site

physician or practitioner.”

CMS does allow the use of mobile devices that include audio and video real-time interactive capabilities,

even though such devices are referred to colloquially as “phones”.

HHS Office for Civil Rights (OCR) is exercising enforcement discretion and waiving penalties for HIPAA

violations against health care providers that serve patients in good faith through everyday

communications technologies, such as FaceTime or Skype, during the PHE for the COVID-19 pandemic.

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12/16/2020

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Telehealth in the ED

In a true telehealth visit the patient and healthcare provider are at separate locations.

Provider at hospital; patient at home or other location.

Patient at hospital; provider at home or other location.

Encounters where the patient and provider are at the same location but using

telecommunication technology to communicate to limit face to face exposure for

the physician and patient and cut down on the use of PPE are coded/billed normally.

These are not telehealth visits.

Telehealth in the ED Performance and

documentation

requirement for ED

visits performed via

telehealth are the

same as a normal ED

visit.

E&M History Exam MDM

99281 Problem Focused

Problem Focused

Straight-Forward

99282Expanded Problem Focused

Expanded Problem Focused

Low

99283Expanded Problem Focused

Expanded Problem Focused

Moderate

99284 Detailed Detailed Moderate

99285 Comprehensive Comprehensive High

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"no-touch" exams for telehealth visitsExample 1

General: appearance/VS

Eyes: EOMs, no icterus

ENT: Mucous membranes moist or dry, malocclusion or not

Lungs: Symmetric chest wall rise, no resp distress, retractions, accessory muscle use or tachypnea

CV: could observe capillary refill when patient pushes on their own skin, look for edema or not

GI: Could comment on distention, have someone tap on their abd for tympany, observe for wincing on family palpation

Musc: look for deformity and comment

Neuro: Ask patient to perform assorted activities for strength, speech

Psych: Observe and comment on mood/affect

Skin: Pink or pale or cyanotic, rashes or spots


ConstitutionalThe general appearance of the patient (e.g., development, nutrition, body habitus, deformities, attention to grooming)

Ears, Nose, Mouth and ThroatExternal inspection of ears and nose (e.g., overall appearance, scars, lesions, masses) Assessment of hearing (e.g., whispered voice, finger rub, tuning fork)

RespiratoryAssessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement)

CardiovascularExamination of extremities for edema and/or varicosities

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MusculoskeletalExamination of gait and stationAssessment of range of motion with a notation of any pain, crepitation or contractureSkinInspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)

PsychiatricDescription of the patient's judgment and insightA brief assessment of mental status, including: • orientation to time, place and person• recent and remote memory• mood and affect

NeurologicTest cranial nerves with a notation of any deficits• 3rd, 4th and 6th cranial nerves (e.g., pupils, eye

movements)• 7th cranial nerve (e.g., facial symmetry)• 8th cranial nerve (e.g., hearing with a tuning

fork, whispered voice and/or finger rub)• 12th cranial nerve (e.g., tongue protrusion

Telehealth and Teaching Physicians

CMS has amended the teaching physician regulations to allow the

presence of a teaching physician during an ED encounter to be met

through direct supervision by interactive telecommunications

technology described above.

Per CMS, the teaching physician must provide supervision either with a

physical presence or be present through interactive

telecommunications technology during the key portion of the service.

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Sample PHE Teaching Physician Attestation

I participated in the key portion of the service via real-time, audio and video telecommunications during the Public Health Emergency due to Covid 19. I discussed the patient with resident and agree with resident's findings and plan as documented in the resident's note.


CMS will allow payment for diagnostic interpretations (x-rays, EKGs, ultrasounds) when the interpretation is performed by a resident under the direct supervision of the teaching physician by interactive telecommunications technology.

The teaching physician must still review the resident’s interpretation.

Medicare will also make payment for teaching physician services when the resident is furnishing these services while in quarantine under the direct supervision of the teaching physician by interactive telecommunications technology.

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The teaching physician must still be present during critical portions of any procedure and immediately available to furnish services during the entire service or procedure.

Given the complex nature of procedures and the potential danger to the patient, even in the context of the PHE, we believe that the requirements for physical presence for either the entire procedure or the key portions of the service, whichever are applicable, are necessary for patient safety. Thus, the PHE exceptions will not apply in the case of surgical or other complex procedures.

Telemedicine and Shared Services

CMS modified the supervision requirements for PA services performed in the office setting, “the

presence of the physician includes virtual presence through audio/video real-time

communications technology when use of such technology is indicated to reduce exposure risks

for the beneficiary or health care provider.”

In response to a query from ACEP, CMS confirmed via email that we could report ED E&M visits

as a shared service if the attending physician has an audio/video interaction with the

patient. This interaction would need to be documented by the attending MD. The service

would be coded with the MD as the provider to be paid at 100% of the allowable.

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Coding Telemedicine in the ED

Coded as a regular ED visit with the ED E&M codes.

• 99281 -99285

Reported with the place of service that would have otherwise been furnished

in person and reported.

• ED = POS 23

Add modifier -95 to any CPT codes reported as a telehealth visit.

Don H Powell, DO, FACEP

(616) 988-8220

[email protected]

Todd Thomas, CPC, CCS-P

(405) 749-2633

[email protected]

www.ERcoder.com

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Coding & Documentation for Telehealth in the ED

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