Billing in Compliance with Recent Telehealth Waivers

On January 30, 2020, the World Health Organization ("WHO") declared the 2019 Novel Coronavirus ("2019-nCoV") disease outbreak a public health emergency of international concern, and on March 11, 2020, the WHO officially declared the Coronavirus Disease ("COVID-19") a pandemic.

As a result of these declarations, the WHO established a new International Classification of Diseases, Tenth Revision ("ICD-10") emergency code, U07.1 2019-nCoV acute respiratory disease.  The Centers for Disease Control ("CDC") announced the new code will be effective and can start being assigned April 1, 2020.  Until the new code is in effect, providers should assign code B97.29 as a secondary code to confirmed cases of COVID-19.  For example, providers should use a symptom code for R50.9 fever and B97.29 Other Coronavirus as the cause of diseases classified elsewhere. As of April 1, 2020, providers should assign code U07.1 2019-nCoV acute respiratory disease to all confirmed cases of COVID-19.

To date, the most frequently used ICD-10 codes related to COVID-19 include: 

• Pneumonia: For a pneumonia case confirmed as due to COVID-19, assign codes J12.89, Other viral pneumonia and B97.29.
• Bronchitis: For a patient with acute bronchitis confirmed as due to COVID-19, assign codes J20.8, Acute bronchitis due to other specified organisms, and B97.29.  For a patient with bronchitis not otherwise specified confirmed as due to the COVID-19, use codes J40, Bronchitis, not specified as acute or chronic, and code B97.29.
• Respiratory Infection: If the confirmed COVID-19 is documented as being associated with lower respiratory infection, not otherwise specified, or an acute respiratory infection, use codes J22, Unspecified acute lower respiratory infection, with code B97.29. If the confirmed COVID-19 is documented as being associated with respiratory infection, not otherwise specified, use codes J98.8, Other specified respiratory disorders, with code B97.29.
• Acute Respiratory Distress Syndrome ("ARDS"): ARDS confirmed due to COVID-19 use codes J80, ARDS, and B97.29. 

For patients who present with a concern of exposure to COVID-19, but exposure is ruled out after evaluation, providers should use code Z03.818, Encounter for observation for suspected exposure to other biological agents ruled out. If there is actual exposure to someone who is confirmed to have COVID-19, providers should use code Z20.828, Contact with and suspected exposure to other viral communicable diseases. 

If a provider documents "suspected", "possible", "probable", or "rule out", code B97.29 should not be assigned. Instead, a provider should assign a code explaining the reason for the encounter, such as fever. If a patient presents with signs and symptoms, and a definitive diagnosis has not been established, a provider should assign the appropriate codes for each of the presenting signs and symptoms. 

Providers should not use diagnosis code B34.2, Coronavirus infection, unspecified, because the cases of COVID-19 have been respiratory in nature, so the site is not unspecified. 

Billing for Medicare Telehealth Services

The Centers for Medicare & Medicaid Services ("CMS") and the Department of Health and Human Services ("HHS") have issued recent waivers that affect how telehealth services are delivered and paid for by Federal government payers.  Under the recently issued Section 1135 waivers, Medicare telehealth services should be billed as if the service had been furnished in-person.  The claim should reflect the designated Place of Service (POS) code 02-Telehealth, to indicate the billed service was furnished as a professional telehealth service from a distant site. 

Medicare typically reimburses providers for three types of telemedicine visits – (1) telehealth visits, (2) virtual check-ins, and (3) e-visits.

Virtual check-ins are a short patient-initiated brief communication for an established patient, for an established diagnosis.  To bill virtual check-ins, providers should use HCPCS codes: 

• G2012: Brief communication technology-based service by a physician or other qualified clinician who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 
• G2010: 5-10 minutes of medical discussion - Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment. Established patients only – same definition as for other E&M services. Verbal consent required – documented in the patient's medical record. No service-specific documentation requirements but medical necessity must be documented. May only be billed by those providers who can perform/bill E&M services.

E-visits include internet-based or email and patient portal communications.  To bill e-visits, providers should use codes: 

• 99421-99423: Online medical evaluation services are non-face-to-face encounters originating from the established patient to the physician or other qualified clinician for evaluation or management of a problem utilizing internet resources. The service includes all communication, prescription, and laboratory orders with permanent storage in the patient's medical record. The service may include more than one provider responding to the same patient and is only reportable once during seven days for the same encounter. 
• 99421 – 99423: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the seven days
• G0425-G0427: Telehealth consultations, emergency department or initial inpatient
• G0406-G0408: Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs
• Office or other outpatient visits 99201-99215 for new and/or established patients. 

Telehealth visits for new or established patients should be billed using the following codes: 

• 99201-99215 (Office or other outpatient visits) Remember that established patient visits only require 2/3 key components when assigning a follow-up visit code.  
• G0425-G0427 (Telehealth consultations, emergency department or initial inpatient)
• G0406-G0408 (Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs).

Finally, there are two new HCPCS codes for providers testing patients for COVID-19.  Providers using the CDC 2019 Novel Coronavirus Real-Time RT-PCR Diagnostic Test Panel may bill for that test using the newly created HCPCS code (U0001), along with the appropriate diagnosis codes as documented by the provider. The Medicare reimbursement under this code is $36.   A second new HCPCS code (U0002) 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC can also be used by laboratories and healthcare facilities.  The Medicare general reimbursement for this code is $51.

Medicaid

States have the option to determine whether and what types of telemedicine to cover under Medicaid. Therefore, providers should check with their state Medicaid program regarding telehealth waivers and billing compliance. 

Commercial Payers

Commercial payers have different requirements for submitting bills for telemedicine visits.  Providers should check each payer's website for updates to ensure compliance with billing requirements.  Specifically, providers should review effective dates, as most insurers are limiting telemedicine exemptions to a specific period of time; services covered; the use of telehealth versus office visit codes, and what modifiers are necessary. ​​​

Update to Billing in Compliance with Recent Telehealth Waivers

On Wednesday, March 25, 2020, we issued the alert, ‘Billing in Compliance with Recent Telehealth Waivers.’  Recent information issued by the Centers for Medicare and Medicaid Services (CMS) on Friday, April 3, 2020 provides updates and modifications to the information contained in the initial alert.  

CMS had previously indicated that claims billed for telehealth services should use the Place of Service Code (POS) 02-Telehealth to indicate the billed service was furnished as a professional telehealth service from a distant site.  However, in information released Friday, CMS indicated that when billing professional claims for all telehealth services for the duration of the public health emergency (PHE), providers should bill with the POS equal to what it would have been had the service been furnished in-person.  In addition, claims should include Modifier 95 to indicate that the service rendered was actually performed via telehealth. 

We will continue to provide updates as CMS releases additional regulations and guidance.