The COVID-19 pandemic massively accelerated the adoption of telehealth services. As a result, virtual visits are now firmly entrenched in healthcare delivery. However, according to the folk at Find-A-Code.com, this rapid telemedicine expansion has created new complexities for medical coding and billing. Mastering coding for telehealth encounters helps ensure accurate billing and optimized reimbursement.
Defining Telemedicine
Broadly defined, telemedicine refers to remote clinical services delivered through communications technology rather than in-person. Patients and providers interact via video, phone, email, apps, wearable devices, and other mediums without being physically present together.
Telemedicine includes a wide range of virtual care like online urgent care, routine wellness checks by phone, remote patient monitoring, transmission of images and data, and video psychotherapy. It aims to improve access, convenience, outcomes, and efficiency through technology-enabled care.
Historically, telehealth faced substantial regulatory barriers and coverage limitations that inhibited widespread adoption. But temporary emergency policies opening up telemedicine access were critical during the COVID-19 public health crisis. Telehealth is now likely here to stay as a permanent and vital part of the care continuum.
Telemedicine Coding Basics
In general, medical coding for telehealth services follows most of the same diagnosis and procedure coding principles and rules as coding for in-person care. However, there are some important nuances that coders must understand to avoid claim denials or reimbursement issues.
Codes must accurately reflect the type of virtual service provided based on the communication medium used. For example, certain Evaluation and Management (E/M) visit codes describe online digital visits, while others specify telephone services. Origin and location codes indicating whether the patient site or provider site originated the clinical encounter may be required as well.
Specific modifiers like 95 or GT need to be appended to explain that the encounter was conducted via interactive audio/video technology. Codes for technical fees, transplantation services, and certain other categories have exceptions to using telehealth modifiers. Rules and requirements keep evolving so coders must diligently stay up to date.
Telehealth Documentation
Thorough documentation is always critical for accurate coding of any patient encounter. However, telemedicine visits have some unique documentation requirements. Along with standard details on history, exam, clinical decision making, and coordination of care, telehealth notes must include:
- Date, time, and duration of the virtual encounter.
- Description of the specific technology used (video, phone, app, etc.).
- Participant names, roles, and locations.
- Confirmation that any data transmitted was sent securely.
Additionally, if any technical audio/video difficulties occurred that impacted services, this should also be noted in the record. Complete documentation covering these aspects confirms the key details needed to assign precise telemedicine codes.
Compliance Considerations
To mitigate fraud risks, telehealth coding must adhere to all general coding compliance principles plus some additional safeguards. Organizations should establish robust training, audits, and technology tools specifically to uphold coding integrity for virtual care services.
Potential problem areas to monitor include unbundling codes that should be bundled, billing for services not fully rendered due to technical glitches, using invalid location codes, and misaligning levels of service with limited documentation. Strict attention to telemedicine-specific rules prevents these types of issues.
Conclusion
Telehealth is here to stay as a vital modality for healthcare delivery and access. While the rapid growth of virtual care has added complexity to medical coding, skilled coders can adapt. Staying up to date on the nuances of telemedicine coding and documentation means they can ensure accurate billing and prevent compliance risks. Telehealth coding shares many similarities with coding for in-person care but also has unique considerations coders must understand. With strong training, auditing, and strict adherence to evolving telemedicine rules, health systems can realize the full potential of virtual care. While telehealth adds challenges, medical coding professionals remain essential to enabling its safe expansion.
