Billing and Coding Telemedicine Services – Key Considerations

Billing and Coding Telemedicine Services – Key Considerations

Consumer demand, changes in reimbursement, and technological advancements are the main factors driving the popularity of telemedicine or virtual medical care. Telemedicine has transformed healthcare, allowing patients to get the treatment they need without leaving their homes. Providers can communicate with patients anywhere and anytime, track their health status, and provide timely interventions. With new remote patient monitoring codes taking effect January 1, 2019, medical coding outsourcing is a practical option for providers to ensure proper reimbursement for telemedicine services or e-consults.

E-consults – Key Takeaways

Telemedicine is recognized or its ability to significantly reduce the cost of treating health conditions as well as risk of readmissions. Telehealth improves care in family practices in many ways. It is also a great option for dermatology, orthopedics, behavioral health and cardiology allowing specialists and hospitals to improve care management and care coordination for underserved communities and the elderly. Telemedicine has proved useful for monitoring chronic conditions such as diabetes and coronary disease, and treating allergies, arthritis, respiratory infections, colds, flu and fever, skin rashes, bladder infections, etc. The American Medical Association is pushing for more telehealth and mHealth in Diabetes Prevention Programs, which use group counseling and one-to-one coaching to improve health and wellness for those at risk of developing type 2 diabetes.

Telemedicine consultations can be of great help when natural disaster strikes. EMS World recently reported on how Lifeguard Ambulance Service used ambulances outfitted with the telemedicine system to serve patients in areas affected by Hurricane Michael that struck Mexico Beach, Florida in October 2018. Telemedicine allowed medical officers to complete assessments and treatments in the patient’s residence that would otherwise need transport to the hospital.

Implementing Telemedicine

Implementing virtual medical care in a primary care practice would involve various steps such as selecting a suitable telemedicine platform, training staff, setting up the equipment, ensuring proper tech support, and informing and educating patients on e-visits. Once the telemedicine platform is set up, the consulting process would be relatively straightforward, especially when the need for specialist care is involved:

  • The primary care physician (PCP) will upload the patient case on the online portal, also providing data such as images or test results.
  • The specialist will be alerted via a text message about the availability of the evisit in the platform. After reviewing the case and making a diagnosis, the information will be sent back to the PCP.
  • With the response received from the specialist on the patient’s concerns, the PCP can treat the patient effectively. The patient would not need to set up an appointment with the specialist.

Telemedicine Coding

Understanding the state’s telemedicine policy and payer guidelines and determining the practice’s telemedicine billing policy is crucial to get paid for services rendered. Providers need to also know which codes to use to bill telemedicine. Commonly used office or other outpatient evaluation and management (E/M) codes for telemedicine include:

  • 99201 – 99205 New patient visits
  • 99212 – 99215 Established patient visits
  • 99241 – 99245 Consultation codes
  • 99406 – 99408 Behavioral change intervention codes

There are also many codes for Medicare Fee-For-Service Providers such as:

  • HCPCS codes G0425 – G0427 Telehealth consultations, emergency department or initial inpatient HCPCS codes
  • HCPCS codes G0406 – G0408 Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs
  • CPT codes 96150 – 96154 Individual and group health and behavior assessment and intervention
  • CPT codes 90832 – 90834 and 90836–90838Individual psychotherapy
  • HCPCS code G0459Telehealth Pharmacologic Management

New Codes in 2019

In 2019, there are new opportunities to get paid for remote healthcare services. Three new CPT codes for Chronic Care Remote Physiologic Monitoring have been introduced, which experts consider a “landmark change” in government efforts to embrace telehealth and mHealth (mhealthintelligence.com). The three new remote patient monitoring codes reflect how health professionals can make better use of technology to connect more efficiently with their patients at home to gather data for care management and coordination. The new CPT codes are:

  • 99453 Remote monitoring of physiologic parameter(s), (for example, weight, blood pressure, pulse oximetry, respiratory flow rate) initial; setup and patient education on equipment use.
  • 99454 Device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.
  • 99457 Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.

Billing Telemedicine – Points to Note

The American Academy of Pediatrics (AAP) offers the following recommendations for billing telemedicine services:

  • Time: Documentation for the encounter should include the required elements for each CPT code has required elements, such as key components or time. As time can be monitored automatically through an electronic encounter, it may be easy document total time spent in counseling and/or coordination of care in the patient record. Only the provider’s face-to-face time with the patient/caregiver is counted toward the level of service provided.
  • The video component required for telemedicine encounters can be billed using a standard CPT code with the 95 modifier.
  • Inclusion of assessments using peripherals such as thermometers, oxygen saturation monitors, spirometers, blood pressure monitors, glucose monitors, etc. in the documentation will support the need for a certain number of required elements for the CPT code being used.
  • Qualifying services also have to be “synchronous,” i.e., they have to be real-time, interactive visits between a patient/family and a clinician.
  • In the “asynchronous” category (for e.g., emails, radiograph and ultrasound studies) clinical information is supplied and considered at a later time. These do not qualify for the process of using the 95 modifier.
  • Effective January 1, 2018, POS 02 is to be used for all telehealth services under Medicare.
  • Before submitting claims, providers should check their state’s rules and payer policies on coverage for telemedicine services.

Studies have reported that remote patient monitoring has a positive impact on patients as it allows them to share data real time with their physicians, leading to more individualized care and enhanced health outcomes. Medicare has expanded telemedicine services eligible for payment in 2019. Partnering with an experienced medical billing company can help providers take advantage of these new opportunities as they focus on enhancing patient reach.

Coding Colectomy – Key Considerations for Claim Submission

An operation to remove part of the intestine (bowel), colectomy is a common procedure performed by general surgeons and colon and rectal surgeons. Given the large number of individual procedure codes available for colectomy procedures, medical billing services are a practical option for surgeons to assign the right CPT codes, stay on top of regulations, and bill their services for maximum reimbursement. A reliable outsourcing firm specialized in general surgery medical billing and coding can help reduce claim rejections and minimize payment delays.

Colectomy – Indications and Types

A colectomy is performed to treat different types of conditions and diseases that may affect the intestines. These include:

  • Inflammatory bowel disease include ulcerative colitis and Crohn’s disease
  • Injury to the bowel, rectum or perineum
  • Ulcerative colitis
  • Crohn’s disease
  • Diverticulitis
  • Colorectal polyp
  • Colorectal cancer

There are different types of surgical procedures involving the colon:

  • Total colestomy – the entire colon is removed and the small intestine is connected to the rectum
  • Hemicolectomy – removing the right or left portion of the colon
  • Proctocolectomy – removing both the colon and rectum
  • Polypectomy – removing a cancerous polyp or polyps from the colon or rectum using a colonoscope
  • Sigmoidectomy – removal of the lower part of the colon which is connected to the rectum
  • Low anterior resection – removal of the upper part of the rectum to treat cancer
  • Abdominal perineal resection – the removal of the sigmoid colon, rectum and anus and construction of a permanent colostomy

There are three approaches to colon surgery: open, laproscopic repair, and robot-assisted laparoscopic resection. The type of operation performed depends on the condition, size of the diseased area or tumor, location, as well as considerations such as health, age, anesthesia risk. In open colectomy, a large incision is made in abdomen and the diseased part of the colon is removed. Laproscopic colectomy involves using a laproscope to perform the surgery through very small “keyhole” incisions in the abdomen.

CPT Codes for Colectomy

To assign the correct codes, experienced medical coders carefully examine the operative reports to determine what procedure or procedures the surgeon performed. The CPT codes for colectomy are as follows:

Traditional open procedure

  • +44139 Mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy
  • 44140 Colectomy, partial; with anastomosis
  • 44141 Colectomy, partial; with skin level cecostomy or colostomy
  • 44143 Colectomy, partial; with end colostomy and closure of distal segment (Hartmann type procedure)
  • 44144 Colectomy, partial; with resection, with colostomy or ileostomy and creation of mucofistula
  • 44145 Colectomy, partial; with coloproctostomy (low pelvic anastomosis)
  • 44146 Colectomy, partial; with coloproctostomy (low pelvic anastomosis), with colostomy
  • 44147 Colectomy, partial; abdominal and transanal approach
  • 44150 Colectomy, total; abdominal, without proctectomy; with ileostomy or ileoproctostomy
  • 44151 Colectomy, total; abdominal, without proctectomy; with continent ileostomy
  • 44155 Colectomy, total; abdominal, with proctectomy; with ileostomy
  • 44156 Colectomy, total; abdominal, with proctectomy; with continent ileostomy
  • 44157 Colectomy, total; abdominal, without proctectomy; with ileoanal anastomosis, includes loop ileostomy, and rectal mucosectomy, when performed
  • 44158 Colectomy, total; abdominal, without proctectomy; with ileoanal anastomosis, creation of ileal reservoir (S or J), includes loop ileostomy, and rectal mucosectomy, when performed
  • 44160 Colectomy, partial; with removal of terminal ileum with ileocolostomy
  • 44320 Colostomy or skin level cecostomy
  • 44322 Colostomy or skin level cecostomy; with multiple biopsies (eg, for congenital megacolon) (separate procedure)
  • 44799 Unlisted procedure, small intestine
  • 45110 Proctectomy; complete, combined abdominoperineal, with colostomy
  • 45111 Proctectomy; partial resection of rectum, transabdominal approach
  • 45112 Proctectomy, combined abdominoperineal, pull-through procedure (eg, colo-anal anastomosis)
  • 45113 Proctectomy, partial, with rectal mucosectomy, ileoanal anastomosis, creation of ileal reservoir (S or J), with or without loop ileostomy
  • 45114 Proctectomy, partial, with anastomosis; abdominal and transsacral approach
  • 45119 Proctectomy, combined abdominoperineal pull-through procedure (eg, colo-anal anastomosis), with creation of colonic reservoir (eg, J-pouch), with diverting enterostomy when performed
  • 45120 Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with pull-through procedure and anastomosis (eg, Swenson, Duhamel, or Soave type operation)
  • 45121 Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with subtotal or total colectomy, with multiple biopsies
  • 45123 Proctectomy, partial, without anastomosis, perineal approach
  • 45399 Unlisted procedure, colon

Laparoscopic procedure

  • 44204 Laparoscopy, surgical; colectomy, partial, with anastomosis
  • 44205 Laparoscopy, surgical; colectomy, partial, with removal of terminal ileum with ileocolostomy
  • 44206 Laparoscopy, surgical; colectomy, partial, with end colostomy and closure of distal segment (Hartmann type procedure)
  • 442Ø7 Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis)
  • 442Ø8 Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anatomosis) with colostomy
  • 4421Ø Laparoscopy, surgical; colectomy, total, abdominal, without proctectomy, with ileostomy or ileoproctostomy
  • 44211 Laparoscopy, surgical; colectomy, total, abdominal, with proctectomy, with ileoanal anastomosis, creation of ileal reservoir (S or J), with loop ileostomy, includes rectal mucosectomy, when performed
  • 44212 Laparoscopy, surgical; colectomy, total, abdominal, with proctectomy, with ileostomy
  • +44213 Laparoscopy, surgical; mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy
  • 44238 Unlisted laparoscopy procedure, intestine (except rectum)
  • 45395 Laparoscopy, surgical; proctectomy, complete, combined abdominoperineal, with colostomy
  • 45397 Laparoscopy, surgical; proctectomy, combined abdominoperineal pull-through procedure (eg, colo-anal anastomosis), with creation of colonic reservoir (eg, J-pouch), with diverting enterostomy, when performed
  • 45499 Unlisted laparoscopy procedure, rectum

Coding Guidance

The Michigan Surgical Quality Collaborative (msqc.org) points out that for the CPT codes that pertain to colectomy, the key elements to look for when assigning the CPT codes are:

  • Approach
  • Anatomical locations or areas of the resection/stapling lines
  • Anastomosis versus Creation of stoma (some procedures use both)
  • Complexity of the procedure

In the Bulletin of the American College of Surgeons dated June 1, 2018, one question in the FAQ section was:

“How do I report an open colon resection and colorectal anastomosis with loop ileostomy for fecal diversion”?

The answer: “You should report CPT code 44146 (see Table 1). Although the CPT descriptor includes the term “colostomy,” the Medicare physician fee schedule work relative value unit (RVU) for this code is based on creation of either a colostomy or an ileostomy. If this same procedure was performed laparoscopically, the correct code to report would be 44208, Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis) with colostomy. It is incorrect to report a code for ileostomy or jejunostomy (44310 or 44187) with a partial colectomy code (for example, 44145 or 44207) for this procedure, as doing so would be unbundling”.

While general surgeons perform a wide range of operations, assigning CPT codes to report even common clinical scenarios can be difficult. Coders in a reliable medical billing and coding company will examine the clinical documentation carefully and assign the right codes to capture the operation, identify separately reportable procedures, and more.