QUESTION: The telehealth rules indicate the service must be patient initiated. What does this mean? We are a pulmonology specialty group and are considering seeing new patient referrals and established patients by Skype. How can the new patient visits meet the office visits’ exam requirements?
Detroit, MI Subscriber
ANSWER: Patient-initiated means that the patient must have requested the service be provided by telehealth. CMS included the patient-initiated requirement to discourage practices from soliciting telehealth services. Medicare specifically did not want their coverage to encourage practices to market that they now offer telehealth services — office visits by audio and video (Skype, Zoom for Healthcare).
However, it is okay to give patients the option of asynchronous (a device that uses two-way audio-video technology) communication in your appointment scheduling and reminders. Explain that both the patient and the doctor will be able to see each other.
Auditors will be examining telehealth claims after the COVID-19 pandemic has ended. To help you avoid future penalties, here are three scenarios that demonstrate appropriate use of 99201-99215 via telehealth.
- Scenario 1: Referrals and follow-ups for a variety of specialties (including pulmonology) are perfect candidates for audio-video telehealth services. The physician himself must have the conversation with the patient through the audio-video link. Medicare is covering telehealth office visits for both established and new patients. Established patient visits require two of the three key components: history, examination, and medical decision-making. You can bill the established patient visit based on history and medical decision-making or two of the three components.
Surprise: A telehealth service can also meet the new patient visit additional requirement of an examination. Some examination can be done without laying hands on the patient. Observation can be done through video. A physician can observe skin tone, abnormal movements, respiratory effort and many other exam elements without being able to necessarily touch the patient. A complete Psychiatric exam can be accomplished through talking with the patient.
- Scenario 2: A patient calls in with complaint of dysuria. The physician documents the complaint (Duration, Timing) and further asks questions about fever, nausea and vomiting (Constitutional and Gastrointestinal Review of Systems). He also reviews the patient’s Past Medical History and Allergies. Based on her previous history, he suspects that the patient has a urinary tract infection and orders an antibiotic.
- Scenario 3: A patient with asthma calls into the practice with an exacerbation. Over the audio, the physician can hear the patient wheezing. Just like in a face-to-face visit, this would be documented as a problem-focused examination.
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