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AAOS Coding Guide for COVID-19

AAOS Member Alert on New CPT Codes for COVID-19

September, 2020

Download and print the AAOS September 2020 Member Alert

On September 8, 2020, the American Medical Association (AMA) created two new Category I CPT codes related to COVID-19 effective immediately.

The first code, 99072, was created to address the additional costs to physicians of maintaining safe protocols during patient in-person visits during the Public Health Emergency (PHE).

The second code, 86413, is the laboratory CPT code for the reporting of quantitative measurements of SARS-CoV-2 antibodies.

Because they are effective as of 9/8/20, these new codes and descriptors will need to be manually uploaded into Electronic Health Record (EHR) systems. The CPT Assistant, Special Edition, contains further details and pertinent Q&As regarding the reporting of these codes.

  • 99072 - Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency as defined by law, due to respiratory-transmitted infectious disease

    To address these additional expenses, the AMA/Specialty Society RVS Update Committee (RUC) worked with 50 national medical specialty societies and other organizations to collect data on the additional costs, and create and implement the new CPT code.

    Per AMA CPT guidance, code 99072 may be reported once per patient in-person encounter regardless of the number of services performed and should only be reported in a non-facility setting. Documentation requirements and coverage may vary among payers, please contact payers for specific policies. The recommendation for reimbursement of code 99072 was submitted to the Centers for Medicare and Medicaid Services (CMS).

    CPT code 99072 may be used from the effective date of 9/8/20 until the end of the PHE, which currently expires on January 21, 2021. Please check with your payer regarding the possible reporting of code 99072 retroactively for services prior to the effective date 9/8/20.

  • 86413 - Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) antibody, quantitative

    This code was created for the reporting of quantitative measurements of SARS-CoV-2 antibodies, as opposed to a qualitative assessment (positive/negative) of SAR-CoV-2 antibodies provided by laboratory tests reported by other CPT codes.

AMA CPT Codes for Telemedicine and Online Digital E/M Services

The following are the current codes in CPT 2020 which can be used to report telemedicine for Evaluation and Management services performed. Under the E/M subheading "Office or Other Outpatient Services," codes are categorized by new and established patients.

New Patients

★ 99201 - Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making

★ 99202 - Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making

★ 99203 - Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity

★ 99204 - Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of moderate complexity

★ 99205 - Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity

Established Patients

★ 99212 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making

★ 99213 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity

★ 99214 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity

★ 99215 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity

Under the E/M subheading "Office or Other Outpatient Consultations, New or Established Patient," CPT codes 99241, 99242, 99243, 99244, and 99245 are used for new or established patients, requiring 3 key components. These codes can also be used when conducting virtual rounding. Modifier 95 should be appended to these codes when reporting telemedicine services in real time.

New or Established Patients

★ 99241 - Office consultation for a new or established patient, which requires these 3 key components: a problem focused history; a problem focused examination; and straightforward medical decision making

★ 99242 - Office consultation for a new or established patient, which requires these 3 components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making

★ 99243 - Office consultation for a new or established patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of low complexity

★ 99244 - Office consultation for a new or established patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity

★ 99245 - Office consultation for a new or established patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity

Note: Telemedicine codes are listed with thedesignation.

Online Digital Evaluation and Management Services

For 2020, three new CPT codes were created -- 99421, 99422, and 99423 -- to report "Online Digital Evaluation and Management" services based on several factors, including time. These codes are reported for established patients and are not performed within 7 days of a previous E/M or procedure.

Note: these are not designated as telemedicine codes.

  • 99421 - Online digital evaluation and management service for an established patient for up to 7 days; cumulative time during the 7 days: 5-10 minutes
  • 99422 - 11-20 minutes
  • 99423 - 21 or more minutes

AMA CPT Codes for Telephone E/M Services for New and Established Patients

CPT codes 99441, 99442, and 99443 under the E/M subheading "Non-Face-to-Face Services," are reported for telephone services based on several factors, including time. These codes may be reported for both new and established patients. This is a change from previous CMS and AMA CPT guidance, as these codes are typically used for established patients only. New and established requirements have been waived for telehealth and telephone visits.

CMS is also increasing payments for these telephone visits to be in line with reimbursement for similar office and outpatient visits. The increase of payments will from a range from $14-$41 to approximately $46-$110. The payments are retroactive to March 1, 2020.

Note: these are not designated as telemedicine codes.

  • 99441 - Telephone evaluation and management service by a physician or other qualified health care professional who may report E/M 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; 5-10 minutes of medical discussion
  • 99442 - 11-20 minutes of medical discussion
  • 99443 - 21-30 minutes of medical discussion

Please note, that one cannot report codes 99441-99443 on a day when the physician or other qualified health professional reports codes 99241-99245. Refer to page 40 of the CPT 2020 for the official CPT rules and guidelines regarding E/M services.

The American Medical Association (AMA) has also created a guide to telemedicine in practice, in which further guidance is provided for telemedicine visits, to accompany CMS’ expansion of access to telemedicine for Medicare beneficiaries.

CMS Telemedicine Reporting Guidelines

Telemedicine benefits for Medicare beneficiaries have been broadened during the COVID-19 outbreak. This CMS press release describes the types of virtual services for Medicare beneficiaries. 

Per the CMS Medicare Telemedicine Healthcare Provider Fact Sheet, providers should use the following codes to report visits where telecommunication systems are used:

  • 99201-99215 - Office of other outpatient visits
  • G0425-G0427 - Telehealth consultations, emergency department or initial inpatient
  • G4046-G4048 - Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs

Additional guidance includes:

HCPCS codes G2010 and G2012 - When a telecommunication system is used for a virtual check-in to determine whether an office visit or other service is needed via telephone or another telecommunications device

HCPCS and CPT codes 99421, 99422, 99423, G2061, G2062 and G2063 - E-visits, defined as communication between a patient and their provider through an online patient portal

Please refer to the CMS Medicare Telemedicine Healthcare Provider Fact Sheet published 3/17/20 for more detailed information, as well as the MLN Booklet for Telehealth Services.

Since some Medicare beneficiaries may have limited access to interactive audio-video technology required for various Medicare telehealth services, CMS is waiving the video requirement for certain telephone E/M services and adding them to the list of covered Medicare telehealth services. These updates can be accessed on the CMS website once they become available. 

Note, CMS refers to these virtual synchronous visits as telehealth, and the CPT term is telemedicine. These terms are interchangeable.

Place of Service (POS) Codes & Modifiers To Be Appended

The Department of Health and Human Services (HHS) and CMS have implemented the following updates regarding the reporting of telehealth services as of 4/6/20. Please refer to the Federal Register for more detailed information.

For Medicare telehealth services, CMS has recommended on an interim basis to:

  • Report the POS code that would have been reported as if the E/M service had been furnished in person.
    • This allows CMS to make appropriate payment for services furnished via Medicare telehealth at the same rate they would have been paid if the services were performed in person.
    • Previous CMS guidelines had instructed to report with the Place of Service (POS) code 02 for Medicare Telehealth to E/M "Office or Other Outpatient Services" codes 99201 – 99215
  • Append the CPT telemedicine modifier, Modifier 95, to E/M services that are reported for telehealth.
    • CMS will maintain the facility payment rate for services billed using the general telehealth
    • Previous CMS guidelines had stated not to use append modifier 95

The POS indicator would be wherever the patient would be seen normally. Therefore, if your typical POS is 11, continue to use POS 11, along with Modifier 95. If your POS is typically outpatient hospital (POS 19 or 22), continue to use that POS, along with Modifier 95. This will render a facility payment such as when seeing patients face-to-face.

Per CMS guidelines, E/M "Office or Other Outpatient Services" codes 99201 – 99215 may be reported for Medicare Telehealth. These codes may not be used for telephone visits. Refer to the CMS website for a complete list of available codes to be used to report telehealth services.

As stated in the Medicare Telehealth Frequently Asked Questions (FAQs), CMS is not requiring additional or different modifiers associated with telehealth services furnished under the current waivers. Physicians participating in the federal telemedicine demonstration programs in Alaska or Hawaii are required to append the GQ modifier to the appropriate CPT or HCPCS code when telehealth services are performed via asynchronous (store and forward) technology. When a telehealth service is billed under Critical Access Hospital, Election of Optional Payment Method (CAH Method II), the GT modifier is required.

AMA CPT 2020 states that Modifier 95, "Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System," should be appended to codes 99241-99245, for reporting telemedicine services performed synchronously (real-time). 

Modifier 95 is defined by AMA as "a real-time interaction between a physician or other qualified health care professional. The totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to face interaction."

See Appendix P of CPT 2020 for a full list of codes that may be used for reporting real-time telemedicine services.

HCPCS Level II Modifier GT is used for services delivered via interactive video and video telecommunication systems. Modifier GQ is used to report services delivered via asynchronous telecommunications system. Please note, that effective January 1, 2018, CMS eliminated the requirements to use the GT modifier when the POS indicator 02 (telehealth) was introduced. One should check with their individual payers to verify if use of the GT modifier is required.

Remember, AMA CPT guidance can differ from CMS guidelines. When coding for a commercial payer, one should check with their individual payer to confirm which guidelines are being used and what their specific reporting requirements are.

ICD-10-CM Codes

The World Health Organization (WHO) has created an emergency use ICD-10-CM code for COVID-19 disease outbreak, U07.1, which is assigned to the disease diagnosis of COVID-19. This code will become effective with the next update scheduled for October 1, 2020. The CDC has provided interim guidance on the reporting of diagnosis codes related to the COVID-19 Coronavirus Outbreak.

COVID-19 Laboratory Testing

On Friday, March 13, 2020, the AMA created a new CPT code effective immediately for the laboratory testing for severe acute respiratory syndrome coronavirus 2 (SARSCoV-2), as defined by the World Health Organization, also known by the disease name, coronavirus disease (COVID-19): 

  • 87635 - "Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, for the reporting of novel coronavirus test"

Please note, code 87635 will be a child code under existing parent code 87471 - "Infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, amplified probe technique."

On April 20, 2020, AMA created two additional CPT codes when patients receive blood tests that detect COVID-19 antibodies:

  • 86328 - "Immunoassay for infectious agent antibody(ies), qualitative or semiquanitative, single step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])"
  • 86769 - "Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])"

The CPT Assistant, Special Edition, contains pertinent Q&As regarding Coronavirus Laboratory Testing, along with a description of the procedure and a clinical example for code 87635. A CPT Assistant update in April addresses the newly created serologic laboratory testing codes. 

Updates

Being that this current situation is fluid, as soon as further coding guidance is available regarding the reporting of E/M services for telemedicine, AAOS will update this document and alert our members immediately. In the meantime, should you wish to view further related information, the following links to the CMS, MLN Matters, and the Medical Group Management Association (MGMA) may be useful.