To facilitate care provided to Medicare beneficiaries in the era of physical distancing, CMS expanded telehealth benefits on a temporary and urgent basis under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act. Medicare’s current guidance on telehealth for nephrology includes previous telehealth guidance issued on January 2019 and changes made to originating site and geographic restrictions to facilitate remote services to kidney patients in March 2020. Medical billing companies can help nephrology practices report remote visits for dialysis patients correctly based on updated telehealth policies.

The new regulations include guidelines for billing and coding remote nephrologist services provided to non-ESRD and dialysis patients. All physician and practitioner activities related to the end stage renal disease (ESRD) monthly capitation payment (MCP) outpatient dialysis services can be provided via telehealth. Two points to note about the expanded telehealth regulations for nephrologists:

  • The telehealth regulations allow nephrology practices to use telehealth platforms to conduct visits with patients on dialysis who are treated at outpatient clinics. Previously, such services were allowed only for patients on home dialysis.
  • The regulations are also valid for visits with patients who have chronic kidney disease, but are not on dialysis. Practices can bill for the same monthly capitated payments for the visits, but it is necessary that the nephrologist makes a live once-a-month visit with the patient in the dialysis clinic or in an office setting.

The key points of current billing and coding guidelines for remote nephrology services as listed by the Renal Physician Association (RPA) is as follows:

  • An originating site is the location where a Medicare beneficiary gets physician or practitioner medical services through a telecommunications system. Significantly, the patient’s home is now an approved originating site for telehealth services.
  • The list of approved distant site practitioners is as follows: Physician and practitioner offices. Hospitals, Critical Access Hospitals (CAHs), Rural Health Clinics, Federally Qualified Health Centers, Hospital-based or CAH-based Renal Dialysis Centers (including satellites), Skilled Nursing Facilities (SNFs), Community Mental Health Centers (CMHCs), Renal Dialysis Facilities, Homes of beneficiaries with End-Stage Renal Disease (ESRD) getting home dialysis, and Mobile Stroke Units
  • The list of approved telehealth services includes:
    • Outpatient office visits-CPT codes 99201-99215;
    • Subsequent hospital care services, with the limitation of 1 telehealth visit every 3 days, CPT code 99231-99233;
    • Individual and group kidney disease education services codes G0420-G0421;
    • All outpatient dialysis services, in-center and home, adult and pediatric, monthly and daily, with the exception of the single visit monthly dialysis codes for all ages, CPT codes 90956, 90959, and 90962
    • Transitional care management services-CPT codes 99495-99496;
    • Advance care planning-CPT codes 99497-99498;
    • Prolonged service codes-CPT codes 99354-99357;
    • Telehealth consultations, critical care-CPT codes G0508-G0509
  • Telehealth services claims should be submitted using Place of Service (POS) 02-Telehealth, to indicate the practitioner furnished the billed service as a professional telehealth service from a distant site
  • The expanded telehealth services can be provided to both new and established patients
  • Documentation requirements for billing patients in isolation: When billing for Patients in Isolation, the physician should:
    • Document that a full-contact physical exam was not possible due to the clinical condition of the patient
    • Document any key findings that they can observe themselves
    • Document key physical findings from the physician who has most recently examined the patient and state why those findings are critical for their renal care
    • Bill at the appropriate level for what the physician “would have done” and document the amount of time spent on the history and physical, focusing on time as it may be meaningful in the event of an audit.
  • CPT codes 99441-443 for Telephone Evaluations- With the lifting of the geographic restrictions for normal E&M services, physician activities that can be captured using these telephonic codes could be provided using E&M codes, provided two-way audio and video capabilities are utilized.
  • Service code G2010 for Evaluation of Recorded Videos or Images-Review of recorded videos or images:
    • Can be done via asynchronous or synchronous technology;
    • Can be done utilizing a patient transmitted photo or video, which requires follow-up with the patient within 24 hours;
    • Are only for established patients, not within 7 days after/1 day prior to an E/M service
  • Service code G2012 for ‘Virtual’ Check-Ins-Brief check-in with an established patient. These services:
    • Must not be related to an office visit that occurred in the previous seven days
    • Must not result in the patient being seen for a next available office appointment or within 24 hours; and
    • Requires 5 to 10 minutes of medical discussion
  • Technology-CMS allows for the use of telecommunications technology that has audio and video capabilities for two-way, real-time interactive communication. Additionally, CMS has also authorized use of telephones that have audio and video capabilities for the furnishing of Medicare telehealth services during the COVID19 PHE. Penalties for HIPAA violations will be waived for health care providers that serve patients in good faith through communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide PHE. This does not allow for the use of audio only telephones.

These changes have expanded telehealth flexibility and ensure that patients follow CDC guidance and social distancing norms to reduce COVID-19 transmission risks. Relying on an experienced medical billing company can help practitioners ensure correct reporting of their remote services.