Exploring New Opportunities for Physicians to Expand Their Reach

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure accuracy. However, HMP and the author do not represent, guarantee, or warranty that coding, coverage, and payment information is effort-free and/or that payment will be received.

Because this issue of Today’s Wound Clinic features the current state of physician payments, Business Briefs will review some new opportunities for physicians and qualified healthcare professionals (QHPs) to expand their reach to the ever-increasing number of patients with chronic ulcers. The Medicare Quality Payment Programs and the private payer contracts are incentivizing physicians/QHPs to improve their quality of care, at the lowest total cost of care (not necessarily using the lowest cost products), while improving their processes of care, and while sharing patient data compliantly with all necessary stakeholders. 

The payers continually tell physicians/QHPs to do the right thing, for the right reason, and at the right time for each of their patients. However, most of the traditional models of care require patients to leave their residences for much of their medical care from physicians/QHPs. In many instances the number of patients who can receive care is limited by constraints such as the number of treatment rooms available. In many other instances, patients with chronic ulcers simply cannot receive care due to transportation issues. Furthermore, many physicians/QHPs are not well-educated in the management of chronic ulcers and cannot receive guidance from specialists unless they can convince their patients to visit the specialists: patients do not like to change physicians and may not have transportation to the specialist. 

In the April 2019 Business Briefs column, we discussed incorporating telehealth into wound management practices. We learned that Medicare has very specific telehealth regulations that originally prevented physicians/QHPs from incorporating it into their business models. Then came the good news: Medicare continues to remove some of the limiting regulations for payment models that focus on improving quality and reducing the total cost of care. 

The Centers for Medicare & Medicaid Services (CMS) provided more good news this year when they released regulations and codes that allow physicians/QHPs to communicate with their patients and with other specialists—and to receive payment for that work. Because the specific telehealth regulations do not pertain to the information that you are about to read, imagine how you can expand your reach to patients who do not qualify for telehealth services.  

What if physicians/QHPs could make home visits to manage chronic ulcers without having to justify the necessity of a home visit to Medicare?

Effective January 1, 2019, the CMS removed the need to justify providing a home visit instead of an office visit. Chapter 12 of the Medicare Claims Processing Manual revised its language about home visits¹: 

Old language: The medical record must document the medical necessity of the home visit made in lieu of an office or outpatient visit. 

New language: Home services codes 99341–99450 are paid when they are billed to report evaluation and management services provided in private residence. 

The CMS also expanded the definition of “home” for use of the existing home visit codes for new patients (99341–99345) and for established patients (99347–99350). In addition to a private residence, home may also include temporary lodging or short-term accommodations—e.g., hotels, campgrounds, hostels, or cruise ships. 

Of course, the CMS has some clear regulations for providing home visits. First, the physician/QHP must have a face-to-face visit with the patient. Second, the place of service (POS) reported on the claim must be POS 12 home. Third, because the work is not performed in a physician’s office, “incident-to” billing is not appropriate. If a QHP provides the home visit, QHPs must use their own provider number on the claim. Finally, the physician/QHP cannot use office visit codes 99201–99215 when reporting home visits. Now that you have this new information, let your imagination and creativity guide you to list the endless possibilities of expanding your reach to patients in their homes! 

What if patients could virtually share information about their chronic ulcers with their physicians/QHPs? 

The CMS created some new codes that allow patients to communicate with their physicians/QHPs and that allow the physicians/QHPs to bill the Medicare program and the patients for this work. Let’s review those new codes: 

G2010 
Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment

Some of the CMS regulations surrounding this service are: 

1. The remote evaluation is intended for established patients. 
2. The remote evaluation requires verbal or written/electronic patient consent before each service is provided. “Blanket” consents are not acceptable. The physician/QHP must inform the patient that the Medicare program and the patient will be charged for the remote evaluation. 
3. The physician/QHP cannot report G2010 if he/she conducted an E/M visit in the previous 7 days.
4. The remote evaluation cannot result in a subsequent office visit with the interpreting provider within 24 hours or the soonest available appointment.
5. As long as the media is compliant with the Health Insurance Portability and Accountability Act (HIPAA), the follow-up by the physician/QHP may be via phone, audio/video, secure text messaging, or e-mail.
6. The quality of the images must be adequate for the physician/QHP to assess the need for medical treatment.
7. The physician/QHP must document the patient’s consent, review and interpretation of images, date and time of beneficiary contact, and content of discussion with the patient.

G2012 
Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

Some of the rules surrounding this service are: 

1. The virtual check-in must be initiated by the patient and requires verbal consent from the patient. The physician/QHP must inform the patient that the Medicare program and the patient will be charged for the virtual check-in. 
2. The virtual check-in must be a real-time, two-way audio and/or video conversation. It cannot be a voice message. 
3. The virtual check-in must be medically necessary for the physician/QHP to receive Medicare payment.
4. The physician/QHP cannot bill this code when the patient contacts she/he about a problem that is related to an E/M visit that took place within the past 7 days or the contact leads to a visit within the next 24 hour or the soonest available appointment. 
5. Calls by the physician’s/QHP’s clinical office staff do not qualify for use of G2012. 

What if physicians/QHPs who do not have wound management expertise could consult with wound-management certified physicians/QHP?

Now physicians/QHPs can have technology-based interprofessional consultations and can receive Medicare reimbursement for their work. In order to use the consultant’s time wisely, the following new code pays the physician/QHP who requested the consultation to prepare for the interaction.

99452 
Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or qualified health care professional, 30 minutes

The CMS regulations for 99452 are as follows:

1. This code is only payable to physicians/QHPs who are eligible to bill for E/M services.
2. The patient’s verbal consent and discussion with the consultant must be documented in the medical record. NOTE: The patient should be informed that she/he will incur a co-payment for this service. 
3. Because this is a time-based code, the treating/requesting physician/QHP must spend 16–30 minutes preparing for the referral and/or communicating with the consultant. In addition, 99452 should not be reported more than once in a 14-day period. 
4. If the time exceeds 30 minutes, the patient is present, and the service meets the criteria for face-to-face prolonged service, used existing codes 99354–99357. 
5. If the time spent exceeds 30 minutes, the patient is not present, and the service meets the criteria for non-face-to-face prolonged service, use existing codes 99358–99359. 

The physician/QHP who provides the requested interprofessional consultation can use the following new code:

99451 
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 minutes or more of medical consultative time

The CMS regulations for 99451 are as follows:

1. If the consultation is less than 5 minutes, this code should not be reported. 
2. If the sole purpose of the communication is to arrange a transfer of care or other face-to-face service, this code should not be reported. 
3. This code is only payable to physicians/QHPs who are eligible to bill for E/M services.
4. The patient’s verbal consent, time spent with the requesting physician/QHP,  topic, and summary of recommendations must be documented in the medical record. 
5. This time-based code requires a written report to the requesting physician/QHP. 
6. The service time is based on total review of medical records, laboratory and imaging studies, medication profile, pathology specimens, and the interprofessional communication time. 

Note how the descriptions and regulations of the existing codes 99446–99449 differ from those of 99451:

99446 
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating /requesting physician or other qualified health care professional; 5–10 minutes of medical consultative discussion and review

99447  11–20 minutes 

99448  21–30 minutes 

99449  31 minutes or more

The CMS regulations for 99446–99449 are as follows:

1. If the consultation is less than 5 minutes, these codes should not be reported. 
2. The majority of the service time reported (greater than 50%) must be devoted to the medical consultative verbal and/or Internet discussion. If greater than 50% of the time for the service is devoted to data review and/or analysis, these codes should not be reported. Instead, the new code 99452 should be reported. 
3. The consulting physician/QHP may not report these codes if she/he has seen the patient within the last 14 days or when the consult leads to a transfer or care or other face-to-face service by the consultant within the next 14 days. 
4. The consulting physician/QHP may only report these codes if the consultation concludes with a verbal opinion report and written report to the treating/requesting physician/QHP. 

What is the current reimbursement for these new codes?

See Table 1 for a display of the national average Medicare allowable rates for the new and existing codes discussed in this article. As you review the allowable rates, keep in mind that most of the new services do not require office space and pay for time spent on more difficult cases.  

Author’s Thoughts

• Because of the specific regulations surrounding these revised and new codes, physicians/QHPs should take time to establish new processes for managing the services before they begin to offer the new services.
  • Establish a process to obtain and document, in the medical record, the patient’s consent before providing the services that require consent: consent must be obtained each time the service is provided. Suggestion: Physicians/QHPs who decide to provide these services should explain 1) the new services, 2) the need for a consent for each service, and 3) the patient’s co-payment responsibility to their patients before they begin offering the services to them. Then the patients will not be surprised when consents are requested and when they receive bills for the co-payment.    
  • Establish a process to monitor that the services do not violate the 7- and 14-day evaluation and management window restrictions.
• Now that Medicare is paying for home visits and technology-based communications, private payers will most likely follow suit. 
• Physicians/QHPs who are interested in expanding their reach to patients with chronic ulcers should review the following topics in the 2019 CPT^® Manual: Home Services, Prolonged Services, and Non-Face-to-Face Services.² n

Kathleen D. Schaum is a founding member of the Today’s Wound Clinic editorial advisory board and oversees a consulting business. She can be reached for consultation and questions by emailing kathleendschaum@bellsouth.net.

1. Medicare Claims Processing Manual. Chapter 12. Available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4309CP.pdf. Accessed June 24, 2019. 

2. Current Procedural Terminology (CPT^®). American Medical Association.