Part 3 – An Overview of New ICD-10-CM’s, Payor Specifics, and Case Studies
This edition would like to throw light on the new ICD-10-CM codes that came into existence during the COVID times and changing Payor specifics when billing for Telehealth. Case Studies are appended to assist coding through real-time scenarios and to elaborate application of coding directives.
New ICD-10-CM Codes by WHO for COVID-19
Under the National Emergencies Act, the Centers for Disease Control (CDC) announced a change in the effective date of new diagnosis code U07.1, COVID-19, originally scheduled to be effective from October 1, 2020, advanced to April 1, 2020.
Changing Payor Specifics
While there are standard guidelines, knowing the Payor specifics is pivotal in enabling the first pass ratio and timely reimbursement of claims.
Here is a quick reference table summarizing the Payor specifics that are evolving as we speak. The below-listed reference is subject to change, and we need to look up the Payor websites for evolving changes.
Most of the above insurances have suspended their Prior authorization requirements on evaluation, testing, or treatment for services related to COVID-19
No Telehealth Modifiers are required for Telephone Services, Virtual Check-Ins, and E-Visits.
State-specific policies to be verified for other payors like Anthem and BCBS.
Case Studies and Coding Rationales
Case study: 1
A 43-year-old established Patient presents for Telehealth service using facetime with URI (Upper Respiratory Infection) symptoms. The patient provided verbal consent to treat. She has URI symptoms from the past two weeks, and it has worsened since the last 2 days. She is a Non-Smoker and has a recent travel history. The provider performs EPF (Expanded Problem Focused) history visually and diagnosed Acute bronchitis with presumptive positive COVID-19, prescribed Augmentin 875 mg P/O and instructs the patient to take an antibody test for coronavirus. Provider spent 15 minutes with the Patient and spent an additional 10 minutes reviewing the Patient’s recent lab reports.
Key Documentation hints for Code Determination:
Visit type: Telehealth
Patient type: Established
Total face to face time: 15 Minutes
Additional time spent: 10 Minutes
Total time spent: 25 Minutes
Choice of Codes and Rationale:
CPT-4: 99214 (No traditional time documentation required for Telehealth visit during PHE per guidelines).
Modifier: GT/95 (Payor specifics apply)
ICD-10-CM’s:
U07.1(Presumptive COVID can be coded as confirmed)
J20.9 (Acute Bronchitis
Case study: 2
A 5-year-old with a rash is scheduled for a Virtual Check-in. The child is an established patient and her mother emailed the pictures of the rash.
Patient/parent location: home,
Date/time of encounter: 3/26/20; 10:00 to 10:27.
The Patient developed a rash all over her body 2 days ago. The rash is not pruritic. She is eating/drinking fine and is active and playful. She did have a recent bout of diarrhea. No fever or vomiting. No URI symptoms. No new soaps or lotions, or other new exposures of which her mother is aware.
Diagnosis: Rash
Plan: Apply 1% Hydrocortisone topical cream to the affected area and advised supportive care for any future episodes of Diarrhoea or Vomiting.
Key Documentation hints for Code Determination:
Visit Type: Virtual Check-In
Patient Type: Established
Time Spent: 27 Minutes
Choice of Codes and Rationale:
CPT-4: 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)
Modifier: Not Applicable
ICD-10-CM: R21(Rash)
Case Study: 3
The Patient is a 93-year-old female who connects today via telephone (audio only) for a routine follow-up visit and requests for a refill of her prescriptions. Verbal consent was obtained for the service via telephone. The patient still has chronic pain and takes Hydrocodone with benefits. Her blood pressure is in the range of 124/70 and does not report any dizziness. The patient also has a history of depression and is well controlled on medication. A refill was provided for Hydrocodone, Lisinopril, and Celexa for chronic pain, hypertension, and depression, respectively. A total of 15 minutes was spent with the Patient on discussion and review of medication dosage.
Key Documentation hints for Code Determination:
Visit type: Telephone
Time Spent: 15 Minutes
Choice of Codes and Rationale:
CPT-4: 99442 (Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian 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; 11-20 minutes of medical discussion)
Modifier: Not Applicable
ICD-10-CM’s:
G89.29 (Other chronic pain)
I10 (Essential (primary) hypertension)
F32.9 (Major depressive disorder, single episode, unspecified)
Case Study: 4
A 70-year-old female calls in via telephone (audio only) with complaints of chest pain and dyspnoea worsening since the last 5 days. The symptoms started 3 weeks ago, and the Patient has been taking Symbicort (2 puffs/day) with some reported relief. The Patient also has a history of allergies and does not have a known exposure to COVID-19. The Provider spent 15 minutes with the Patient and instructed her to be seen in the office tomorrow for a CBC, an EKG, and may need an X-ray based on the physical exam. The Provider wants to do a full work-up before prescribing oral steroids. The Patient agrees to be seen in the office the next day.
Key Documentation hints for Code Determination:
Visit type: Telephone
Time Spent: 15 Minutes
Choice of Codes and Rationale:
No service should be reported for this case since the Provider has scheduled a face to face visit within 24 hours
In our next edition, we will focus on commonly overlooked telehealth coding guidelines, denial trends, and how to prevent them. Happy learning and talk to you in the next edition….
About the Authors
Sree Mura Devi J, BPT, CPC carries over 12+ years of Multi-Speciality Coding experience leading the Coding Training division at Access Healthcare. In her role, Sreemura ensures our coders stay up to date with the dynamic coding industry updates in addition to driving Coder certification training.
Malarvizhi Tholgappian, BPT, CPC comes with 14+ years of Multi-Speciality coding expertise currently playing the role of a Project manager assisting Transition of new coding projects at Access Healthcare. In her role, Malarvizhi facilitates coordinated work efforts between, Operations leaders, trainers, and the end customer enabling a smooth transition.
Malar V, B. Pharm, CPC has over 10 years of hands-on expertise in Multispecialty E/M coding playing the role of a Process Trainer at Access Healthcare. Malar as well supports knowledge needs on new coding transitions and her domain knowledge on resolving the grey areas with E/M coding is commendable.