COVID-19: Intersection of Telehealth and the 2021 Evaluation and Management Changes

Health Solutions | Corporate Finance & Restructuring

April 27, 2020

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The COVID-19 public health emergency (PHE) has created an opportunity for a significant expansion of telehealth services across the spectrum of healthcare services and payers. The Centers for Medicare and Medicaid Services (CMS) has promulgated substantial new regulatory guidance to expand the availability of telehealth.

Providers bill for all types of visits using the Common Procedural Technology (CPT) Evaluation and Management (E&M) codes published and maintained by the American Medical Association, with additional regulatory guidance from CMS for governmental payers. Because there are challenging aspects to documenting a telehealth visit, CMS is allowing physicians who perform telehealth services to prematurely adopt a modified version of the CPT coding changes previously scheduled to go into effect January 1, 2021 for office and outpatient hospital services (CPT codes 99201-99215).

These “new” documentation standards are only for telehealth visits that will be billed using the 99201-99215 series of codes and do not apply to in-person visits or other types of E&M services (such as inpatient visits) even if performed via telehealth.

Historically, E&M service codes require the documentation of various levels of history, physical examination, and medical decision-making that are defined in the CMS 1995 and 1997 Guidelines. Time is a factor in determining the code level billed only when greater than 50% of the visit is spent counseling and coordinating care.

A typical time associated with most CPT codes is published in the CPT book, and the type of setting for the service is factored in. For example, office services have typical face-to-face time while inpatient services have bedside or hospital unit time.

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