Kara Wong Ramsey, MD

Telemedicine services, a real-time interaction between a physician or other health practitioner and a patient located at a distant site, have become increasingly more widespread since the COVID-19 pandemic. During the COVID-19 public health emergency, Centers for Medicare and Medicaid Services (CMS) emergency waivers increased flexibility for healthcare providers to offer telemedicine services. This was accomplished by expanding the coverage of audio-video synchronous telemedicine to incorporate more Current Procedural Terminology (CPT®) services, including critical care and other inpatient services, and place of service (POS) codes to account for the receipt of telehealth in a patient’s home. CMS waivers also now allow for coverage of certain CPT® services felt appropriate for audio-only telemedicine without video and include services such as behavioral health-related services and physical/occupational therapist services. Although the public health emergency is over, these waivers will be extended to at least December 2024.

There are several important aspects to remember when billing for telemedicine services. The same CPT®for an equivalent face-to-face encounter should be used. For neonatologists, common scenarios for using telemedicine may include outpatient office visits for prenatal consultations or NICU follow-up clinic visits. The time spent or complexity of the telemedicine interaction must be sufficient to meet the key components or requirements of evaluation and management CPT® codes used when the same service is rendered face-to-face. When telemedicine services provide the CPT®services, an appropriate modifier should be added. Modifier 95 is used for synchronous audio-video services. Modifier 93 is used for audio-only visits (including telephone) when applicable. Additionally, the place of service code should be reported for the distant site (where the patient is located) and the originating site (where the provider is located). Codes for the distant site include 02 for telehealth provided in a place other than the patient’s home or 10 for telehealth provided in the patient’s home. 

Question: 

You have a scheduled outpatient prenatal consult visit via telemedicine on a secured 2-way audio video conferencing platform for a 24-year-old G1P0 woman at 34 weeks gestation with a fetus with gastroschisis, as requested by her primary Ob-Gyn. You spend 10 minutes reviewing her medical chart. Your MA confirms the patient’s consent for telehealth services over the phone before you connect via your telemedicine platform for 5 minutes. You spend 15 minutes reviewing with the patient the plan for NICU admission after delivery with silo placement, central line placement, surgical repair, and anticipated NICU stay while gradually advancing feeds and weaning off of TPN according to your unit protocol and answer her questions. You additionally spend another 10 minutes completing your documentation of the consultation and another 10 minutes coordinating care with your multidisciplinary NICU regarding this anticipated NICU admission. 

Which CPT®Code and Modifier would you use? 

1. 99242 initial outpatient consult, 20-29 minutes 
2. 99243 initial outpatient consult, 30-39 minutes 
3. 99244 initial outpatient consult, 40-54 minutes 
4. 99245 initial outpatient consult, 55 minutes 
5. Modifier 93 audio-only telemedicine 
6. Modifier 95 audio video telemedicine 

Answer: C (CPT®99244 initial outpatient consult 40-54 minutes) and F (modifier 95 audio video telemedicine) 

This vignette presented a new outpatient office consultation, with the proper outpatient office visit CPT®code based on time spent (sum of both face-to-face and non to face to face time, including preparation work) and modifier to reflect the use of synchronous audio-visual telemedicine. 

To ensure proper reimbursement, in addition to including the required elements to substantiate your chosen CPT®code (such as the reason for consultation and the name of the requesting physician for a consulting service), your documentation of a telemedicine encounter must include the following elements. 

Patient consent: 

You need to document that the patient gave you verbal or written consent for the telehealth encounter. This can be done by either the provider or another staff member, as done by the MA in this scenario. 

Time of visit: 

While you may count the time you spent preparing for the encounter, face-to-face time, documentation, and care coordination, you may not count the time that other staff members spent during the encounter. Therefore, similar to an in-person visit, you cannot count the 5 minutes the MA spent in consenting and preparing for the telehealth encounter. 

Originating and distant site: 

Your documentation should list the originating site (where the provider is located) and the distant site (where the patient is located). Your POS codes should also reflect these locations. 

Name of the telemedicine platform used: 

The telemedicine platform used must comply with Health Insurance Portability and Accountability Act (HIPAA) Rules and follow HIPAA business associate agreements to ensure adequate protection of patient privacy. 

References:

1. AMA telehealth policy, coding, and payment. American Medical Association. Updated July 19, 2023. https://www.ama-assn.org/practice-management/digital/ama-telehealth-policy-coding-payment
2. What the end of the COVID-19 emergency means for telehealth. Updated June 2, 223. https://www.ama-assn.org/practice-management/digital/what-end-covid-19-emergency-means-telehealth

Disclosures: Dr. Wong Ramsey is a Fellow of the American Academy of Pediatrics and a member of the Coding Committee of the Section on Neonatal-Perinatal Medicine since 2020.