Adding to the Tool Chest: Virtual Visits for Chronic Pain

Summary:

Pain practitioners are in a unique position to utilize the new waivers and changes that pertain to telehealth and other virtual visits. However, the rules covering these services are complex, nuanced and ever-changing. Today's alert explores these services and their requirements.

Many of our chronic pain clients have fully embraced telehealth and other virtual services as a means of augmenting their practice during the national health emergency (NHE). The advantage of adding these new implements to the clinical tool chest is that they allow providers to continue their diagnosis and treatment of patients without unduly risking the spread of viral agents. Many, however, are unsure about the rules for documenting and billing these services, as well as the scope of services that are actually available. This is certainly understandable as there has been a proliferation of new rules addressing virtual visits in recent weeks—with perhaps more changes to come.

With that in mind, it is our purpose to summarize, below, the types of services that are available to pain providers who wish to minimize unnecessary exposure during the viral outbreak.

Telehealth Visits

From a definitional standpoint, telehealth is a means by which a provider can conduct patient visits without being in the physical presence of the patient. There is no telehealth code set in the CPT coding manual; rather, several existing code sets within that manual may come under the telehealth rubric when certain conditions are met. Some of those codes include the primary evaluation and management (E/M) codes used in chronic pain clinics, such as the office/outpatient codes for new and established patients, 99201–99205 and 99211–99215, respectively. Medicare payment under telehealth for these codes will be the same as had the services been face-to-face.

The primary condition of payment under telehealth is that the provider must conduct the patient visit using real-time, two-way communication that includes BOTH audio AND visual components. This can be accomplished by way of technologies such as Skype or FaceTime on an iPhone. (The government released new rules on April 30 that added some gray to the visual requirement, but this initially appeared to apply only to a limited set of codes that are typically not applicable to the practice of chronic pain, such as behavioral health). Another condition of billing telehealth is that the provider and patient must be in different locations (e.g., the provider is in the office and the patient is at home). A third condition is that the telehealth service must be initiated by the patient, though the provider is encouraged to advise the patient of the availability of such services. As far as patient consent to such services, a recent CMS fact sheet states:

Beneficiary consent should not interfere with the provision of telehealth services. Annual consent may be obtained at the same time, and not necessarily before, the time that services are furnished.

When documenting telehealth visits, you may list the typical elements you would normally document during a regular in-person visit, i.e., history, exam and medical decision-making (MDM). The visual functionality of the technology you will be utilizing during the telehealth visit is what allows you to perform at least some portion of the exam element of the E/M. Most importantly, you will need to indicate on the E/M report that the encounter was by way of telehealth. At a minimum, denote the word "telehealth" in the report.

According to the Interim Final Rule released in April, you may also document office/outpatient services (99201-99215) performed via telehealth based on either (a) time (obviating the history, exam and MDM documentation requirements) or (b) the MDM component alone. If basing the service on time alone, you would need to list the total number of minutes you spent with the patient performing the service.

Telephone Visits

The CPT manual contains a set of telephone visit codes that reflect audio-only visits with patients. While these have not typically come under the "telehealth" umbrella (at least one Medicare MAC now classifies them as telehealth), they do stand as a reasonable option for chronic pain providers during the NHE. These are time-based codes, and so billing is based on the number of minutes you spend with the patient, rather than hitting a certain number of history, exam and MDM bullets. Nevertheless, your documentation should include the issues discussed and any findings or medical decision-making involved as a result of the call. You will also need to document the amount of time spent in direct contact with the patient. Finally, you should specify in your documentation that this was an "audio-only" visit. 

The telephone codes are as follows:

• *99441 – 5 to 10 minutes with the patient
• *99442 – 11 to 20 minutes with the patient
• *99443 – 21 to 30 minutes with the patient

As with the telehealth rules, telephone visits must be patient-initiated. While the CPT manual stresses that these services are relegated to established patients only, the recent federal waivers allow you to also utilize these services for new patients during the NHE—at least as to Medicare. The recent rule changes also provide that Medicare reimbursement for these audio-only services match payments for similar in-person office and outpatient visits. According to estimates, this would mean an average increase in payments for these services from a range of about $14-$41 to about $46-$110. The increased payments are retroactive to March 1, 2020.

Providers should be aware that there are a few hurdles to consider when billing from the telephone visit code set. First, the call cannot originate from a related E/M provided within the previous seven days. Second, the call cannot lead to an E/M or procedure within the following 24 hours or next available appointment.

E-Visits and Virtual Check-ins

A fact sheet released by CMS in recent weeks related that, as of January 1, Medicare will pay for communication with an established patient where the patient initiated the communication through an online patient portal. These "E-visits" are reflected by CPT codes 99421-99423, which can be submitted by physicians and providers who are allowed to bill for E/M services.

Similarly, the same CMS fact sheet advised that Medicare will pay for "virtual check-ins," using HCPCS code G2012 (5-10 minutes of medical discussion). This service describes a brief patient-initiated communication with the provider by phone, patient portal or HIPAA-compliant video service. Code G2010 describes a remote evaluation of recorded video and/or images submitted by patient. The provider may respond to the patient's check-in via a number of modalities, including phone, text, email or portal.

While the virtual check-in remains an option to chronic pain providers, there are a few requirements you must meet, including the following: 

• *You cannot bill G2012 where the patient had a visit within the previous 7 days.
• *The virtual check-in must not result in a visit within the succeeding 24 hours.

While CMS expects these check-ins to be initiated by the patient, the provider should inform the patient of the availability of such visits.

For both E-visits and virtual check-ins, you will want to document the type of service (e.g., "E-visit") and any relevant information or decision-making as a result of the encounter. In addition, the patient's verbal consent to receiving such services (obtained at least annually) needs to be memorialized in the patient's chart.

Hipper HIPAA

The Office of Civil Rights (OCR)—the HIPAA enforcement agency within HHS—has indicated it will not be targeting providers for the use of Skype, FaceTime or similar modalities during the NHE. As a result, many of the privacy and security concerns that preceded the current pandemic have been temporarily removed in order to prioritize patient care.

Narcotics Waivers

According to the Drug Enforcement Agency (DEA) and HHS, telehealth may now be used to prescribe certain controlled narcotics. As of March 16, and continuing for the duration of the NHE, DEA-registered practitioners may issue prescriptions for all schedule II-V controlled substances to patients for whom they have not conducted an in-person medical evaluation, provided all of the following conditions are met:

• *The prescription is issued for a legitimate medical purpose by a practitioner acting in the usual course of his/her professional practice;
• • *The telemedicine communication is conducted using an audio-visual, real-time, two-way communication system; and
  • *The practitioner is acting in accordance with applicable federal and state laws.

While the in-person visit requirement has been temporarily waived by the federal government, the individual states may have their own rules in place. Many of these states have already waived certain drug-prescribing requirements during the current environment. However, chronic pain providers must check with their own state authorities to determine the status of any such rules or waivers.

Temporary Tools

As quickly as these new rules have been created, they can just as quickly be revised, reworked or rescinded. Once the NHE is over, we may see the beginning of this process—a process that will take once-effective tools out of the hands of providers and put them neatly away. It is possible; however, that a few of the temporary rules promulgated to respond to the COVID crisis will remain. The government will no doubt undertake a study to determine the safety and effectiveness of these ad hoc waivers and allowances and may ultimately determine that some should be retained. So, when it's all said and done, providers just might get to keep a couple of shiny new wrenches in the old toolbox.

If you have questions about any of the virtual services described in this article, please reach out to your account executive or contact us at info@anesthesiallc.com.