Author: Tony Mira
Prevention of the spread of COVID is essential during this time. Treatment from a distance is one of the strategies being employed in the pursuit of that goal. Yes, there are ways in which anesthesia providers can bill for patient services without actually being in the same room as the patient. This article explores some of those ways.
Virtual Visits: Anesthesia Meets Telemedicine
A pop diva from the 1980s once boldly declared that we are living in a material world. While that remains the case to be sure, we can add to that maxim that we are increasingly living in a virtual world, as well. This is especially true in the age of COVID. Over the last few years, many had already begun the practice of replacing face-to-face relationships with those that flourished online inside of chat rooms and remote work stations and interactive gaming parties. With the advent and spread of the coronavirus, the previous trend toward virtual interaction has now been accelerated and solidified. As we all know, the recent calls for social distancing and sheltering in place have been extended to the health delivery space, hence the new rules involving virtual medicine coming out of Washington.
Rules and More Rules
There have been multiple rules and waivers put into place since the inception of the national health emergency (NHE). Many of these have attempted to address the problem of providing care while mitigating potential exposure to the coronavirus. Where clinicians can effectively communicate with patients without occupying the same physical space, governments and payers have relaxed rules to encourage that. Generally, such services fall within the “telehealth” umbrella, but there are other types of services that also come into play. To what extent, then, can anesthesia providers make use of these new rules?
The most recent telehealth provisions allow you to bill a myriad of codes, such as those reflecting evaluation and management (E/M) services and critical care, without actually being in the same location as the patient. From a strict sense, telehealth has historically referred to virtual visits between provider and patient by means of real-time, two-way communication that must contain both audio and visual components. So, while you’re not physically present with the patient, you are both speaking with them and seeing them, such as with Skype or FaceTime on an iPhone. The important point here is that without the visual component, the service has not been deemed telehealth until recently.
Within minutes of completing the initial draft of this article, CMS issued brand new guidance regarding telehealth that overturns portions of their previous “new guidance.” Here is the latest information from CMS:
Since some Medicare beneficiaries don’t have access to interactive audio-video technology that is required for Medicare telehealth services, or choose not to use it even if offered by their practitioner, CMS is waiving the video requirement for certain telephone evaluation and management services, and adding them to the list of Medicare telehealth services. As a result, Medicare beneficiaries will be able to use an audio-only telephone to get these services.
We will need to determine over the next few days the precise E/M services included in this latest waiver.
Is Telehealth Relevant to Me?
So, the question arises: does telehealth really cover what anesthesiologists and CRNAs are currently doing within their new practice parameters? One of the key conditions of billing a code under the telehealth umbrella is that you and the patient must be in separate locations. In other words, the government does not intend for telehealth to come into play if you and the patient are in the same facility. On April 17, the Centers for Medicare and Medicaid Services (CMS) published a set of FAQs that addressed, in part, telehealth. Here is an excerpt that may prove instructive:
Question: Should on-site visits conducted via video or through a window in the clinic suite be reported as telehealth services? How could a physician or practitioner bill if this were telehealth?
Answer: Services should only be reported as telehealth services when the individual physician or practitioner furnishing the service is not at the same location as the beneficiary. If the physician or practitioner furnished the service from a place other than where the beneficiary is located (a “distant site”), they should report those services as telehealth services. If the beneficiary and the physician or practitioner furnishing the service are in the same institutional setting but are utilizing telecommunications technology to furnish the service due to exposure risks, the practitioner would not need to report this service as telehealth and should instead report whatever code described the in-person service furnished.
Given this guidance, let’s look at a scenario that some of our clients are now facing. Let’s say that you are in the hospital and you need to perform a postoperative pain round. You don’t want to enter the patient room because to do so would require an extra amount of time to gear up with personal protective equipment (PPE). Accordingly, you decide to simply call the patient from the floor to check on their pain level, etc. This would be an example of where you could not bill a code under the telehealth rules because you are in the same facility as the patient.
Yes, there is a telephone services code set, reflecting audio-only communication (no visual component), and it appears that the new telehealth rules just issued will increase payments for 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. However, the rules surrounding this code set require the call to be initiated by the patient, which typically is not going to happen in a pain round. So, once again, there are hurdles to overcome. (It should be noted that some payers allow these calls to be initiated by the clinician during the NHE. We have seen guidance from at least one state Medicaid and one Medicare jurisdiction to this effect.)
Getting Paid for Virtual Visits
While the government is going to great lengths to loosen certain restrictions, it is nonetheless frustrating to find the above roadblocks in the path of providers who are simply trying to care for patients in the most efficient and prudent way possible. There is, however, a means by which anesthesia providers in the hospital setting may still get fully paid for their rounds—even where they do not physically see the patient.
Unless you are rounding on a patient with an indwelling epidural catheter, postoperative pain rounds will typically involve the subsequent hospital care code set (99231-99233). This code set requires that you document two out of the following three elements:
- Patient History
- Patient Exam
- Medical Decision-making (MDM)
From a practical perspective, you cannot perform a physical examination of a patient without seeing the patient. So, the exam element of the E/M requirements is a no-go in an “out-of-room” round. However, relatively new E/M rules allow you to meet the history element by simply reviewing the patient’s history that was obtained, in-full, by ancillary staff (you should document such review). In addition, you can perform and document the MDM element of the service without being present with the patient. In such a scenario, you will have documented two out of the three elements required to bill a “regular” (non-telehealth) E/M round.
Now, let’s look at a scenario where you are performing a postoperative pain round on a patient with an indwelling epidural catheter. We would normally bill that service out with the daily pain round code, 01996, which pays a little more than the E/M codes. However, when submitting 01996, you are being paid to evaluate/manage the epidural itself, as well as the patient. You might typically inspect the insertion site, look at and/or change the dosage settings, determine if there are any issues with the catheter, etc. In other words, you need to be in the room to fully perform this service. If you choose not to be in the room while rounding on such a patient, we recommend billing this service from the subsequent hospital care code set, listed above. Again, you will still need to document your review of the patient’s history and your medical decision-making.
Another scenario that is presenting itself to our clients during the NHE is critical care. Technically, it may be possible to perform such services without physically seeing the patient since these are time-based codes, and part of that time can include non-patient-facing services. However, this may not prove to be of practical value—at least in many cases—since much of what anesthesia providers are being asked to perform in the ICU requires them to be at the patient’s bedside.
The Foreseeable Future
We don’t know how long the need for limiting exposure to COVID patients will persist—whether through the use of PPE or rounding from a distance. Yes, some facilities will soon be opening up to so-called elective surgeries, but that doesn’t mean that the risk of COVID infection will be completely gone. Indeed, we’re being warned of an “inevitable second wave” by leading experts. Therefore, even as surgeries ramp back up, some will want to continue to practice under conditions that will limit the virus’ ability to spread. Virtual rounds, then, may be an option chosen by many anesthesia providers well into the fall.
If you have questions about other telemedicine services or virtual visit issues, please do not hesitate to contact your account executive. We look forward to providing you information that will benefit both you and your practice during this extraordinary time.