EDITOR’S NOTE: This article was originally published online last week, but following review by members of the editorial board to correct minor factual errors, it has been revised and republished.
The COVID-19 pandemic has brought about robust changes to the traditional practice of healthcare in the United States. In a time of social distancing and widespread quarantining, regulatory bodies, including the Centers for Medicare & Medicaid Services (CMS), have adapted to the current environment. The most critical goal was to allow healthcare providers to appropriately care for a potential surge in COVID-19, while providing distanced access for both COVID-19 and non-COVID-19 patients seeking preventative health, acute, or chronic disease management.
Healthcare providers have been allowed to practice medicine across the country without the need for additional state licensure. Hospital systems were informed they could expand or create physical bed spaces in non-traditional locations to handle a surge in patient numbers. Outpatient and in-home capabilities have also been expanded to provide access while maintaining appropriate distancing.
Changing regulations on documentation, reporting, and auditing has allowed healthcare providers to better focus efforts on patient care. Lastly, telemedicine access has been substantially increased, which has changed the potential future of healthcare in the United States. Together, these quick and purposeful decisions created an environment to appropriately care for all patients affected by the pandemic.
In order to reduce the exposure of many acute and chronically ill patients, traditional outpatient visits were strongly discouraged during the COVID-19 pandemic. Many of these outpatient services were transitioned to telemedicine practices as part of the pandemic response .
CMS designed three types of encounters for this transition. Phone appointments are used for telephone evaluation and management (E&M) for a new or established patient, distinct from other encounters. A distance (or distant) health visit can be provided in place of an initial or follow-up outpatient visit. For established patients, providers could initiate a virtual check-in for a brief evaluation of a problem, and to further guide a patient’s care. Finally, e-visits allow established patients to communicate with their provider through an online portal. These have to be initiated by the patient, and the communications can occur over a seven-day period.
Each of these require documentation using visit type and time spent. Use of standard templates and documenting consent is best practice, except for e-visits for which consent is a requirement. Providers are permitted to waive the copay for Medicare patients (see Table 1).
Table 1. Billing codes and documentation requirements for outpatient distance health visits (Adapted from Cleveland Clinic COVID-19 Response, Digital Health Playbook.)
Phone appointment calls (audio only)
● 99441-99443 (5-30 minutes)
● 99358-99359 > 30 minutes
● Telephone visit type
● Standard template
● Consent suggested
● Time spent
Distance health visit (audio+video)
● New patients:
○ Level 1-5 (99201-99205)
● Established patients:
○ Level 1-5 (99211-99215)
● Virtual visit type
● Standard template
● Consent suggested
● Time spent
E-Visits (non-face to face, online, portal based)
● Physicians and other qualified providers: 99421, 99422, 99423
● Qualified non-physician visit (e.g., physical therapists): G2061, G2062, G2063
● Initiated by the patients via online portal
● Standard template
● Consent required
● Time spent (Cumulative up to seven days)
The end-stage renal disease monthly visit requirement has been changed to every three months, with many other flexibilities in existing requirements also implemented.
Resident physicians may provide any level of an office or outpatient E&M visit, telephone E&M encounter, care management, and communication technology-based service. These flexibilities do not apply in the case of surgical, high-risk, interventional, or other complex procedures, services performed through an endoscope, and anesthesia services.
Inpatient services ranging from initial hospital care to critical care can be provided via telemedicine visits using some of the CPT® codes listed below. CMS has clarified that if a hospital visit is conducted with audio-visual technology, but the physician is anywhere on the hospital campus, that is not considered a telehealth visit and should be billed as a face-to-face visit with no modifier. For coding purposes:
- Initial and subsequent hospital care and hospital discharge day management (CPT codes 99221-99223; CTP codes 99231-99233, CPT codes 99238- 99239)
- Initial nursing facility visits, all levels (low, moderate, and high complexity) and nursing facility discharge day management (CPT codes 99304-99306; CPT codes 99315-99316)
- Critical care services (CPT codes 99291-99292)
- Inpatient neonatal and pediatric critical care, initial and subsequent (CPT codes 99468- 99469; CPT codes 99471-99473; CPT codes 99475- 99476)
- Initial and continuing intensive care services (CPT code 99477- 99478)
- Psychological and neuropsychological testing (CPT codes 96130- 96133; CPT codes 96136- 96139)
Appropriate documentation templates or phrases should be developed and used to reflect a telehealth inpatient visit.
For consultations, various virtual visit platforms integrated into the institution may be used by clinicians to assess patients, provide recommendations, and manage them remotely.
Virtual visits or telephone visits can be scheduled by working with patients, sometimes involving multidisciplinary teams. This service is being reimbursed by specific CPT codes 99451-99452 and G0406-G0408, with follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or sub-acute nursing facilities.
The medical record should contain the request for the consult, with an explanation of the medical necessity. The consulting physician should provide a verbal and written report to the requesting/treating clinician.
Billing for procedures performed at bedside or in the procedural areas remains the same as prior to the pandemic. Supervision requirements allow for use of virtual tools in certain non-surgical scenarios.
Appropriate billing modifiers, especially when billing for E&M virtually, are important to make the distinction between the service provided and time spent to provide the service.
Although new International Classification of Diseases (ICD-10) codes have been developed to accurately capture documentation of COVID-19 patients and suspected cases globally, in the United States, there is only the ability to capture definitively diagnosed cases. The clinician may rely upon their clinical judgment or perform a confirmatory test. If diagnosing COVID-19 on pattern recognition, the clinician should document that with verbiage such as “COVID-19 by clinical judgment.”
For a non-pregnant patient with a definitive principal diagnosis of COVID-19, assign code U07.1, COVID-19, first, followed by the appropriate codes for associated illnesses such as acute respiratory illness, renal failure, etc. If the provider documents an uncertain diagnosis, using modifiers such as “suspected,” “possible,” “probable,” or “inconclusive” COVID- 19, U07.1 is not assigned; instead, the code for symptom or other manifestation (e.g., acute bronchitis) would be indicated.
For acute respiratory illness due to COVID-19, use U07.1, followed by the appropriate code depending on the presentation, such as J12.89, other viral pneumonia, or J20.8, Acute bronchitis due to other specified organisms.
For pregnant or peripartum patients, the Chapter 15 diagnosis codes (O00-O9A) take sequencing priority, as usual. In these cases, use the principal diagnosis code O98.5, Other viral diseases complicating pregnancy, followed by U07.1. If there is a respiratory manifestation like pneumonia, O99.5-, Diseases of the respiratory system complicating pregnancy, childbirth and the puerperium, would be appropriate as well.
Sepsis due to COVID-19 is another exception, and it also displaces U07.1 as the principal diagnosis. There is no unique code for viral sepsis, so A41.89, Other specified sepsis, is utilized. U07.1 and other manifestations, like viral pneumonia, are secondary diagnoses.
For patients presenting with any signs or symptoms associated with COVID-19 (such as fever), but for whom a definitive diagnosis has not been established, assign the appropriate code(s) for each of the presenting signs and symptoms, such as R05 for cough or R50.9 for fever, unspecified.
The diagnosis code Z20.828-, Contact with and (suspected) exposure to other viral communicable diseases, is the justification for all pending or negative testing for SARS-CoV-2 during the pandemic. Coding authorities instruct coders to await results to assign codes and drop bills. If the test is positive, they are permitted to pick up the code for COVID-19. During the pandemic, Z20.828 can also be used if ordering a COVID-19 test preoperatively to ensure a patient does not have COVID-19 prior to undergoing surgery.
If a patient is seen after a bout of COVID-19, the proper verbiage is “history of COVID-19,” and the correct code is Z86.19, Personal history of other infectious and parasitic diseases. This is especially important if the patient has a persistently positive PCR test, which is believed to be a result of inactive viral remnants, not indicative of a current COVID-19 infection.
Quality and Compliance
While new temporary standards and definitions have been created to guide documentation and billing during the COVID-19 public health emergency, hospital quality and compliance teams should formulate policies and implementation guides. Routine audits need to be done to ensure appropriateness of documentation and submission of billing codes.
Patient privacy and data safety still remain of the utmost importance, and every effort should be made to have policies and procedures implemented to safeguard them.
Emergency response to the COVID-19 pandemic has necessitated changes in requirements for documentation of care and billing at all levels of patient care. Standard templates and phrases help in ensuring compliant capture of required documentation.
Creation of policies, procedures, and distance health technology guides, such as in the digital health playbook created by Cleveland Clinic, should be accomplished to provide guidance for appropriate care, documentation, and billing.
Documentation and billing requirements for non-governmental insurers may vary. Also, due to the dynamic nature of this guidance, every effort should be made to stay current with documentation and billing guidelines from national and local authorities. Revisions and updates come out quite frequently.