Coding & Documentation for
Telehealth in the ED
TODD THOMAS, CPC, CCS-P DON H POWELL, DO, FACEP
Telehealth in the ED
Telehealth requires “Interactive telecommunications system that includes, at a minimum, audio and video
equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner.”
CMS does allow the use of mobile devices that include audio and video real-time interactive capabilities, even though such devices are referred to colloquially as “phones”.
HHS Office for Civil Rights (OCR) is exercising enforcement discretion and waiving penalties for HIPAA violations against health care providers that serve patients in good faith through everyday
Telehealth in the ED
In a true telehealth visit the patient and healthcare provider are at separate locations. Provider at hospital; patient at home or other location.
Patient at hospital; provider at home or other location.
Encounters where the patient and provider are at the same location but using
telecommunication technology to communicate to limit face to face exposure for the physician and patient and cut down on the use of PPE are coded/billed normally. These are not telehealth visits.
Telehealth in the ED
Performance and
documentation
requirement for ED
visits performed via
telehealth are the
same as a normal ED
visit.
E&M History Exam MDM
99281 FocusedProblem Problem Focused Straight-Forward
99282 Expanded Problem Focused Expanded Problem Focused Low 99283 Expanded Problem Focused Expanded Problem Focused Moderate 99284 Detailed Detailed Moderate
99285 Comprehensive Comprehensive High 3
"no-touch" exams for telehealth visits
Example 1
General: appearance/VS Eyes: EOMs, no icterus
ENT: Mucous membranes moist or dry, malocclusion or not
Lungs: Symmetric chest wall rise, no resp distress, retractions, accessory muscle use or tachypnea CV: could observe capillary refill when patient pushes on their own skin, look for edema or not GI: Could comment on distention, have someone tap on their abd for tympany, observe for wincing on family palpation
Musc: look for deformity and comment
Neuro: Ask patient to perform assorted activities for strength, speech Psych: Observe and comment on mood/affect
Skin: Pink or pale or cyanotic, rashes or spots
"no-touch" exams for telehealth visits
Example 2
Constitutional
The general appearance of the patient (e.g., development, nutrition, body habitus, deformities, attention to grooming)
Ears, Nose, Mouth and Throat
External inspection of ears and nose (e.g., overall appearance, scars, lesions, masses) Assessment of hearing (e.g., whispered voice, finger rub, tuning fork)
Respiratory
Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement)
Cardiovascular
Examination of extremities for edema and/or varicosities
"no-touch" exams for telehealth visits
Example 2
Musculoskeletal
Examination of gait and station
Assessment of range of motion with a notation of any pain, crepitation or contracture
Skin
Inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)
Psychiatric
Description of the patient's judgment and insight A brief assessment of mental status, including: • orientation to time, place and person • recent and remote memory
• mood and affect
Neurologic
Test cranial nerves with a notation of any deficits • 3rd, 4th and 6th cranial nerves (e.g., pupils, eye
movements)
• 7th cranial nerve (e.g., facial symmetry) • 8th cranial nerve (e.g., hearing with a tuning
fork, whispered voice and/or finger rub) • 12th cranial nerve (e.g., tongue protrusion
Telehealth and Teaching Physicians
CMS has amended the teaching physician regulations to allow the
presence of a teaching physician during an ED encounter to be met
through direct supervision by interactive telecommunications
technology described above.
Per CMS, the teaching physician must provide supervision either with a
physical presence or be present through interactive
telecommunications technology during the key portion of the service.
Sample PHE Teaching Physician Attestation
I participated in the key portion of the service via
real-time, audio and video telecommunications
during the Public Health Emergency due to Covid
19. I discussed the patient with resident and agree
with resident's findings and plan as documented in
the resident's note.
Telehealth and Teaching Physicians
CMS will allow payment for diagnostic interpretations (x-rays, EKGs, ultrasounds) when
the interpretation is performed by a resident under the direct supervision of the teaching physician by interactive telecommunications technology.
The teaching physician must still review the resident’s interpretation.
Medicare will also make payment for teaching physician services when the resident is
furnishing these services while in quarantine under the direct supervision of the
Telehealth and Teaching Physicians
The teaching physician must still be present during critical portions of any
procedure and immediately available to furnish services during the entire service or procedure.
Given the complex nature of procedures and the potential danger to the patient, even in the context of the PHE, we believe that the requirements for physical presence for either the entire procedure or the key portions of the service, whichever are applicable, are necessary for patient safety. Thus, the PHE exceptions will not apply in the case of surgical or other complex
procedures.
Telemedicine and Shared Services
CMS modified the supervision requirements for PA services performed in the office setting, “the
presence of the physician includes virtual presence through audio/video real-time
communications technology when use of such technology is indicated to reduce exposure risks for the beneficiary or health care provider.”
In response to a query from ACEP, CMS confirmed via email that we could report ED E&M visits
as a shared service if the attending physician has an audio/video interaction with the patient. This interaction would need to be documented by the attending MD. The service would be coded with the MD as the provider to be paid at 100% of the allowable.
Coding Telemedicine in the ED
Coded as a regular ED visit with the ED E&M codes.• 99281 -99285
Reported with the place of service that would have otherwise been furnished
in person and reported.
• ED = POS 23
Add modifier -95 to
