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Virtual Services During the Time of COVID-19

Public and private insurers have taken steps to increase telehealth services during the public health emergency due to COVID-19. CMS is expanding its Virtual Services benefits on a temporary and emergency basis. The expanded benefit is retroactive to March 1, 2020 and allows patients to receive care at their place of residence rather than in a physician office or a hospital. The most recent expansion included payment for telephone calls with patients.

Part of the expanded benefits include allowing telehealth services to be reported by a variety of non-public facing technologies. The requirement for synchronous audio/visual requirements remains. Services can be reported for both new and established patients and should be reported using the same code (i.e. 99201-99215) that would have been reported if the patient was seen for an in-person visit. Reimbursement will be the same as if the patient was seen in the office or other appropriate setting. Levels of service for office visit codes can be based on either time or medical decision-making. It is not necessary to meet the documentation requirements related to the key components (history, exam, medical decision-making) when selecting a level of service.

Based on input from the medical community, CMS previously announced that Medicare would pay for certain services conducted by audio-only telephone between beneficiaries and their doctors and other clinicians. Now, CMS is also increasing payments for these telephone visits to match payments for similar office and outpatient visits. This would increase payments for these services from a range of about $14-$41 to about $46-$110. The payments are retroactive to March 1, 2020. The codes for telephone services (99441-99443) are time-based services and have restrictions on reporting when they are provided in conjunction with other patient encounters. It is important to read the CPT instructions for reporting telephone services to understand the requirements and limitations associated with these codes.

AAPM offered a webinar “Coding Services in the Wake of COVID-19” on April 15 that addresses the appropriate coding and reporting of telehealth services and other virtual services covered by Medicare. The webinar can be accessed here.

AAPM also convened a panel of pain medicine experts to present a webinar, “Pain Management Best Practices During the COVID-19 Pandemic and Public Health Crises: A Discussion of the New Guidelines.” This webinar is also available and can be viewed here.

Guidelines are changing as payers attempt to revise policies and adjust their systems to meet policy changes. You should visit your Medicare, Medicaid and private payers’ websites and/or read all payer communications to determine coverage and specific instructions. 

AMA Releases Coding Advice Related to COVID-19

  The AMA has created a quick reference flow chart for CPT reporting for COVID-19 testing that outlines coding options for testing patients for COVID-19. Although testing is not likely to be ordered by pain medicine practices, the flow chart summarizes the coding options for telemedicine, telephone and “virtual check-in” visits. Most of these options were explained in a previous article.

Physicians have contacted AAPM with concerns for caring for patients who are high-risk and do not have internet capabilities or skills. Medicare does not cover the codes for telephone services. However, Medicare pays for “virtual check-ins” (brief communication technology-based service) for patients to communicate with their doctors and avoid unnecessary trips to the doctor’s office. These virtual check-ins are for patients with an established (or existing) relationship with a physician where the communication is not related to a medical visit within the previous 7 days, and does not lead to a medical visit within the next 24 hours (or soonest appointment available and involves 5-10 minutes of medical discussion. The service is reported using HCPCS code G2012.

Patients must verbally consent to receive virtual check-in services; however, you can advise patients of the availability of the service. Medicare coinsurance and deductible apply to these services. The national average reimbursement for code G2012 is about $15.

A new page on the AMA website address CMS payment policies & regulatory flexibilities during COVID-19 emergency.

Incorrect Billing of HCPCS L8679 – Implantable Neurostimulator

CMS has issued a MLN (Medicare Learning Network) article concerning the inappropriate reporting of HCPCS supply code L8679 (Implantable neurostimulator, pulse generator, any type) for electro-acupuncture devices. These devices are applied behind the ear using an adhesive and/or with needles inserted into the patient’s ear and do not require surgical implantation.  

Code L8679 should only be reported with procedures that require surgical implantation into the central nervous system or targeted peripheral nerve. These procedures are usually performed in an operating room. The MLN article (number SE2001) provides a list of appropriate procedures that must accompany any claims that include code L8679. It can be accessed here.

As of March 1, 2020, claims billed with HCPCS L8679 must be billed with the same date of service as the applicable surgical procedure code. Claims for code L8679 reported with an appropriate surgical code will be suspended for medical review to verify that coverage, coding, and billing rules have been met. Claims submitted without an appropriate procedure code will be rejected.

Please make sure your coding and billing staff are aware of the correct use of code L8679 and the changes in the CMS policy. The National Coverage Determination Manual Section 160.7 on implanted peripheral nerve stimulators is available here.

Upcoming RUC Survey

In the next few weeks we will be contacting a random selection of members to participate in an important AMA/Specialty Society Relative Value Scale Update Committee (RUC) survey of physician work for codes 64633-64636 which describe destruction of facet joints. The Medicare payment schedule is based on physician work, practice expense and professional liability insurance. Our specialty needs your help to assure relative values will be accurately and fairly presented to the Centers for Medicare and Medicaid.  

AAPM is conducting this survey for the RUC in partnership with several other medical specialties including the American Academy of Physical Medicine and Rehabilitation, American Society of Anesthesiologists, and the Spine Intervention Society. If you are a member of one or more of these additional societies, you may see a survey request from them (rather than from AAPM). In such instance, we ask that you treat their request as similarly vital. We will compile all relevant survey data from the partnering societies for our presentation to the AMA RUC.

The survey is being conducted at the request of the RUC and stems from issues related to budget neutrality. As part of the RUC process, specialty societies must provide an estimated utilization for any new or revised family of codes. CMS productivity data dating back to 2014 identified concerns related to the use of the add-on codes that identify each additional joint treated. The possibility of incorrect coding of per nerve instead of per joint was discussed and a CPT Assistant article was published in February 2015. Changes were made to the 2016 CPT guidelines for this group of codes clarifying the correct reporting of the add-on codes. The RUC allowed time for these efforts to take effect and reviewed the utilization data again in October 2019. The Relativity Assessment Workgroup (RAW) of the RUC noted that the growth in these services is appropriate as patient population requiring these services has grown. However, due to the extensive growth and original incorrect assumptions about distribution of reporting, the Workgroup determined that a new survey is required.

If you receive a request to survey these codes, please remember your input in this survey is vital. The specialty societies ability to impact the work recommendations is dependent on robust and meaningful data. If you have any questions, please contact Emily Hill, AAPM Coding and Reimbursement Liaison, at: [email protected].

Pain Management Codes Posted

The Coding and Reimbursement Committee has updated the coding information available on the AAPM website. New charts have been posted that include information concerning Medicare’s 2020 Relative Value Units (RVUs) for codes commonly reported by Pain Medicine Physicians. The title page provides links to CMS web pages that provide additional information and outlines the basis for the 2020 reimbursement rates.

The charts are organized according to the type of service (e.g. E/M, injections, radiology) with new and revised codes highlighted. As appropriate, some charts contain information indicating which codes include imaging guidance as well as which codes can be reported with the bilateral modifier. The Relative Value Units in the charts reflect the combined RVUs for physician work, practice expense and professional liability (total RVUs). RVUs in the “facility” column are used to calculate payments in the hospital or other facility setting. RVUs in the “non-facility” column are used for services provided in a physician office.

There is also a separate worksheet that lists all the new and revised codes for 2020. CPT 2020 introduces new codes for genicular and SI injections and makes significant changes to the instructions for reporting all somatic nerve injection codes. These changes are outlined in an AAPM E-News article, dated December 18, 2019.

Access the chart of common pain medicine codes online (login required).

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