Jonathan Rubenstein, MD

The year 2020 has been challenging for everyone. The Centers for Medicare & Medicaid 

Services (CMS) has made several unprecedented changes to adapt to the coronavirus disease 2019 (COVID-19) public health emergency (PHE), with other payors following suit. 

However, as stay-at-home orders are lifted, we are seeing several payors roll back or partially roll back some of the implementations regarding the use of telehealth. The health care system changes are only a fraction of the challenges each urology office is facing. We have been impressed with the innovation and outside-the-box thinking that many have taken on and shared with others to meet the challenges facing us. We encourage you to keep thinking and trying new things.

For this article, we are going to focus on a “burning” question that we have been asked repeatedly: With all that is happening, is CMS going to move forward with the adoption of new guidelines for E/M office coding?

Briefly, we can answer with a qualified “Yes.”

We are writing this article just prior to the release of the proposed rules for the Physician Fee Schedule. For a refresher on Medicare rule making, CMS releases a proposed rule for physician payment each year toward the end of the second quarter (late June or early July). This rule allows CMS to receive and react to suggested changes in the way physicians will be paid during the following year. Societies and individuals can provide direct feedback to CMS with arguments for or against these changes. Medicare reviews this feedback and incorporates its response in the final rule, which is typically released in October or early November. The final rule sets the policy for the forthcoming year. CMS is also required to accept and review comments on this rule, but it is unusual for the agency to make major changes at this stage.

Recall that the final rule for 2020, released in November 2019, included a commitment to adopt the upcoming changes in evaluation and management (E/M) codes, revise the relative value units (RVUs) for office and other outpatient E/M codes, and add or adopt codes to address additional time and impacts on certain specialties.

CMS also partially adopted the proposed documentation changes for 2021 E/M codes to allow for services provided via telehealth during the PHE. In short, our qualified “yes” regarding whether or not CMS will adopt the E/M changes for 2021 is based on what CMS has published. In addition, the American Medical Association (AMA) has indicated they will proceed with an updated publication of the office and other outpatient Evaluation and Management Services Guide, required for use under HIPAA. Our answer is qualified because CMS has not yet issued the final rule and, as we have seen, the agency could make alterations at the last minute.

We will focus on a few highlights of the upcoming changes and the preparations we recommend for the remainder of this year.

Second, and more importantly, history (H) and physical (P) examination will no longer follow the requirements currently included in the guidelines for 1995 or 1997. Instead, the new guidelines require only that the documentation include a medically necessary and appropriate H and P.

Hopefully, all of you have been using this new approach to H and P for your telehealth visits provided for Medicare and your Medicare advantage plans during the PHE. CMS adopted this change to the documentation guidelines for telehealth in its March 30 rule. Adapting to the change allows you to charge more appropriately regarding the medical decision making required for remote office visits. It should also give you a partial road map to the changes you may need to make to your EMR templates and patient intake forms, which can be fully implemented on January 1, 2021.

We encourage you to contact your electronic medical record (EMR) vendor to find out whether they are planning to update the current E/M calculator. Regardless of whether your vendor is able to keep up with the changes, we encourage you to learn the new rules in preparation for the changes so you can report the correct code for the services you provide now and in the future.

The other change adopted for the PHE was the amended definition of time. Although the 2021 updates in current procedural terminology will take things a step further by including revised time ranges for each E/M new and established office visit, the concept has already been implemented during the PHE for telehealth visits. Currently, time can be used as the overriding factor if you spend over 50% of the E/M face-to-face visit time in counseling and/or coordination of care, and document it. Under the new definition (again, currently allowed for telehealth visits), you can use time to select the appropriate level of service reported regardless of how much time you spent in counseling and/or coordination of care. In addition, the new definition of time allows you to count the total time spent during the date of service in support of the E/M encounter. For documentation, you will need to record total time. This includes time spent directly with the patient, reviewing records, discussing with other providers, coordinating care, and so on.

We do not yet know the extent of detail you may need to document. As is the case today, you are not required to document time unless it is to be used to determine the level of service charged. Further, although time is appropriate for some encounters, most urology encounters would be more accurately and efficiently reported by reviewing the medical decision making required.

The new guidelines rely primarily on the medical decision making documented. These proposed changes were not adopted for the PHE but will be adopted on January 1, 2021, for all new (99202-99205) and established (99211-99215) office visit codes. The new guidelines for medical decision making will require some education as the changes published by the AMA have been revised. The changes to this portion of the E/M office new and established patient guidelines include the same main categories of Number of Problems, Amount of Data, and Amount of Risk. What has changed is the way in which these categories will be divided by level.

Number of Problems is now based on severity of problem, with little accommodation for the number of problems addressed. Amount of Data is grouped by category, and the number of categories and amount of data for each category are used to determine the appropriate level of service. Amount of Risk is similar to the existing risk table, but has been simplified by grouping the former three columns of risk into one table representing the risk of morbidity from additional diagnostic testing or treatment.

We urge you to take time this fall to educate yourself on these changes. The American Urological Association and Physician Reimbursement Services will be offering courses on the new system over the remaining months of 2020, as well as providing support in 2021. Further, follow up with your EMR vendor to ascertain what changes if any are being made to your system to accommodate these updates. Although change is always difficult, we feel that these changes will be of great benefit to urologists once they are implemented. Get ready and embrace this challenge.

The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

Articles

The deletion of code 99201 is among the evaluation/management coding changes for 2021.

It’s time to prepare for upcoming E/M coding changes

Perineal biopsy has been performed since the early 1980s and has recently seen a resurgence. How should one code for performing a perineal biopsy?

The typical code to use will be CPT 55700, which describes prostate biopsy by any approach. Imaging can be added if appropriately performed and documented.

There are 3 CPT codes that describe the sampling of prostate tissue by biopsy: CPT codes 55700, 55705, and 55706. Each is described below.

55700: Biopsy, prostate; needle or punch, single or multiple, any approach.

 CPT code 55700 is used for prostate biopsy by any technique, whether transrectal, perineal, or endoscopic. CPT code 55700 can be billed with or without imaging guidance, such as ultrasound, so imaging guidance can be billed separately if performed. This code should be reported once per session no matter how many cores are obtained, and there is no upper limit to the number of cores taken to bill 55700 once. The procedure may be performed in the nonfacility (office) or facility (ambulatory surgery center, hospital) setting. This procedure is a 0-global day procedure.

Note: Imaging for this procedure is often provided with transrectal ultrasound. We remind you that although in the past, Medicare allowed for reporting of both the diagnostic ultrasound (76872 ultrasound, transrectal) and ultrasound guidance (76942 ultrasonic guidance for needle placement [eg, biopsy, aspiration, injection, localization device], imaging supervision and interpretation), this is no longer appropriate, as they are now bundled. Many private payers are following Medicare’s lead and are also bundling the 2 codes. Therefore, when using ultrasound in conjunction with the biopsy code 55700, you will need to select the appropriate imaging code supported by the documentation and medical necessity.

55705: Biopsy, prostate; incisional, any approach.

 CPT code 55705 is the code to use for an “open” prostate biopsy, by surgical exposure of the prostate, with cores taken by direct visualization of the prostate. The work of this code includes obtaining tissue from the prostate by direct incisional sampling and specifically describes the need to make a surgical incision and tissue dissection to expose the prostate. The procedure may be performed in the facility (ambulatory surgery center, outpatient, or inpatient hospital) setting and is a 10-day global procedure.

55706: Biopsies, prostate, needle, transperineal, stereotactic template-guided saturation sampling, including imaging guidance.

 CPT code 55706 is used for the performance of a “saturation” biopsy. A true saturation biopsy is a unique procedure that is performed in specific indications and following the steps as defined by the American Medical Association (the owner of the CPT copyright):

• The patient has a prior suspicious biopsy, or a prior negative biopsy [result] with rising PSA [prostate-specific antigen].

• The procedure is performed in an operating room under general or spinal anesthesia.

• A template grid to map the (entire) prostate gland is used. This grid enables the physician to remove cores at 5-mm intervals using a stereotactic approach.

• Cores are taken at 5-mm intervals, and each specimen is labeled to correspond with the location of each core chosen. In deeper planes, both a proximal and distal biopsy may be obtained.

• Each biopsy sample is marked for its coordinates, and all are mapped in 3D to determine the extent and exact position of malignant cells.

• Typically, 35 to 60 biopsies are taken, based on the size of the gland.

CPT code 55706 should not be performed in the office setting, as there are no practice expense inputs to reimburse for supplies, clinical staff, or equipment. This is a 10-day global procedure, and imaging guidance is included so imaging cannot be billed separately.

Why is CPT code 55700 typically the correct code for performing a perineal biopsy?

Perineal biopsy is correctly reported using CPT code 55700 prostate biopsy, any technique. As stated in the descriptor, CPT code 55700 should be used for any technique of prostate biopsy, including perineal biopsy, no matter how many cores are taken and even if using a stepper or grid. This code was valued with consideration of the typical time, skill, and resource use for the performance of the procedure by any route, including both capital and disposable costs. As perineal biopsy was being performed when this code was valued, the time skill and resources needed for the performance of biopsy by any technique were included in the value.

It would not be proper to bill CPT code 55706 for a typical perineal biopsy. CPT code 55706 is to be used only for a saturation biopsy and only if the indications and steps outlined by CPT are followed. Although saturation biopsy is performed by the perineal approach, one should not confuse the definitions and choose CPT 55706 unless a true saturation biopsy is being performed, even if the perineal biopsy is extensive and performed in an operating room.

Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o 

Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

Three codes are available for prostate biopsy, but only one is typically used for perineal biopsy, according to Jonathan Rubenstein, MD, and Mark Painter.

How to code for a perineal prostate biopsy

I need some guidance on billing for the bladder scan procedure (51798). As it is a technical-only code, can this be billed in place of service (POS) 21 when a patient is inpatient or in ED POS 23 when performed outside of a uroflow procedure? Also, can it be billed in POS 22 as part of the uroflow procedure with 51741 and 51784? Typically, I have billed this with POS 11, but I need some guidance on whether it is billable to ED, inpatient, or outpatient hospital.

First, you are correct that current procedural terminology (CPT) code 51798, measurement of postvoid residual (PVR), is a technical-only code and therefore has no work value. Unfortunately, if you look into Medicare’s resource-based relative value scale (RBRVS), the actual value assigned to the Nonfacility Practice Expense Value is NA (not applicable), meaning the code will not be paid if performed in a place of service 21 or 23. The service is considered paid for in the facility payment provided to your hospital.

As for the second part of your question about POS 22 (on campus-outpatient hospital), this is also a facility place of service and therefore the 51798 will not be paid. As you indicated, it is appropriate to report 51741 and 51784 for any place of service listed above (21, 22, or 23), with modifier -26. You will be paid the facility rate for the services. Typically, the facility rate does not change the work Relative Value Units associated with the procedure, but often pays slightly less due to a lower practice expense value.

Remember, using data in each case to provide treatment may allow you to include the data provided from 51798 as part of the data section for Medical Decision Making, which can affect the level of service selected for evaluation and management (E/M) services provided to the patient on that date or another date. Documentation of the visit must include the value (PVR in mL) from the service and support the data’s use in the patient’s treatment or in the diagnosis. Although this is not a substitute for payment received in the office setting, it is the appropriate use of the data based on the code and value.

CPT 51798 will not be paid if performed in place of service 21 or 23, according to Jonathan Rubenstein, and Mark Painter.

Coding for bladder scan raises several questions

We have been speaking with many of you directly as states react differently to the arrival of the coronavirus in the United States. Stay-at-home orders and canceling of elective surgeries are spreading at the time of this writing. Many urology practices have already seen massive cancellations of in-office visits and surgical services. Others are preparing for changes that are coming.

As we hear from urologists and practices around the country, the primary concerns are centered around continued care for patients while maintaining the health and safety of both patients and staff. We have heard of many new and creative solutions for social distancing in the office setting for those patients requiring face-to-face care. It is impressive to see the talent and intelligence of the urology community.

We have also been impressed with the efforts of industry and the specialty organizations to help urologists stay up to date, push for legislative actions that allow for appropriate continuity of care, and in keeping the urology community at large in touch with one another. Keep thinking, keep planning, keep watching, and keep sharing. It takes a village, now more than ever.

For this article, we will focus on telemedicine and telehealth services. We will share what we know at this time, but know that changes are happening very quickly as payers, the government, patients, and practices react to this unprecedented crisis. There are several websites we encourage you to monitor to keep abreast of changes (see “Online coding resources”).

In discussing the various options for remote services, we will first establish a vocabulary. Although many use these terms interchangeably, we are going to separate services into the following categories:

Telemedicine is the use of synchronous audio and visual communications to deliver health care at a distance.

Telehealth is the use of electronic and telecommunications technology to deliver asynchronous health care at a distance.

There are a number of platforms that will allow you to interact with your patients using audio and visual communication. Prior to the COVID-19 outbreak, Medicare provided coverage to more than 100 CPT services as long as patients receiving care were located in a Medicare-approved facility located (“originating site”) in a Health Professional Shortage Area (HPSA). The list of covered services included evaluation and management services, mental health, opioid addiction care, end-stage renal disease services, and other services deemed medically appropriate.

During this crisis, Medicare has relaxed several of the requirements for providing and billing for telemedicine services because during this public health emergency they believe patients should avoid unnecessary travel to physicians’ offices, clinics, hospitals, or other health care facilities where they could risk their own or others’ exposure to further illness. Here, we provide a summary of the changes and how they affect the urology office.

Medicare relaxed the originating site requirements and the HPSA requirements during the outbreak. Therefore, established patient outpatient visits 99212-99215 can be reported when provided to any patient regardless of the patient’s location as long as the visit is conducted using a live audio and visual connection. Documentation for the visits has been relaxed and allowing level selection to be based on time spent that date related to the service or Medical Decision Making.

Payment for each code will be made at the same level as if the service were provided face to face in the outpatient setting. Billing requires you report the code for the visit using place of service 11 (the place-of-service code for office). A physician can provide these services from their home or other appropriate location. For purposes of billing, the location address for services should be the office number assigned to your Provider Transaction Access Number regardless of the actual location of the physician.

CMS has clarified that it will not enforce the requirement that remote services be reported only for patients with whom the physician has a prior relationship, allowing you to provide new patient visits remotely (99201-99205). Documentation requirements are also relaxed, allowing level selection based on Medical Decision Making and time the same as established patient visits.

Medicare beneficiaries are generally liable for their deductible and coinsurance. However, to reduce the potential financial burden on Medicare beneficiaries, the Department of Health and Human Services Office of Inspector General stated they would provide flexibility for health care providers to reduce or waive cost-sharing for telehealth visits paid by federal health care programs. Should you choose to waive co-payments for these services, be careful to be consistent when offering this to patients. This option has been announced and may be expected by patients.

You may wish to develop a process for telemedicine visits that includes having the front desk speak with the patient with regard to billing and payment, having a medical assistant or nurse assist you to collect relevant history complaints and making sure the video and audio connection is of sufficient quality, and finally commencing the visit with the physician. The first two steps, up until the establishment of the connection, can be conducted with audio (telephone) only and can be accomplished prior to the visit similar to the flow established for an in-office visit.

Multiple options for obtaining patient forms/signatures

Forms typically required for new patients, including release forms, HIPAA policy explanation, and financial policies, can be obtained through patient portals. CMS has stated that forms can be signed after the visit has been provided and can be blanket coverage for an annual period, a verbal consent should be obtained and documented in the patient record.

As not all patients are well versed in the portal or use of the Internet, under the relaxation of HIPAA during the crisis, you should be able to use services like DocuSign to acquire patient signatures and other documents normally required when a new patient joins the practice. It also appears that you would be able to send forms via email and receive a scanned document (encrypted if possible) or returned via picture and messaging to the office; use this as a last resort.

Numerous applications can be used, such as What’s App, that allow pictures to be sent in an encrypted format directly from a phone to a computer instead of using mobile phones in the office. 

HIPAA rules have been relaxed as well. You are free to use FaceTime and Skype to conduct these visits without a Business Associate Agreement for CMS. You are required to take reasonable precautions such as avoiding the provision of these visits without others in the room who are not employed by your office. Further, we encourage you to respect your patients, explaining the purpose of others required in the room. If you have HIPAA-compliant tools, you should use them when possible.

In 2019, CMS expanded the ability to provide services remotely by adding new codes and extending coverage to new CPT codes for services provided using the telephone and other telecommunication platforms. The expanded coverage for these services prior to the COVID-19 outbreak required that the patient was an established patient, the patient initiated the encounter, the encounter was not related to an E/M visit provided in the last 7 days, and the visit did not result in instructions to have the patient come to the office at the next available appointment. The codes for these services and the descriptions are provided in the table

G2012 (Brief communication technology-based service, eg, virtual check-in) is intended for telephone calls initiated by a patient that are not related to or in follow-up of a recent E/M service for which the provider can manage the patient on the phone and the call does not lead to an in-person visit. It is important to document in the chart that the patient met these criteria, consented to the call, and understands that a bill will be sent to Medicare.

Code G2010 is a similar code, but when there is asynchronous (not real time) services provided (“store-and-forward”). During the COVID-19 outbreak, CMS has stated clearly that these services and six new service codes for Telephone only services 99441-99443 and 98966-98968 can be provided to new and established patients expanding the ability for continuity of care for your patients. The requirement for patient initiation of these visit types has also been relaxed during the crisis.

Finally, in regard to these services, if the patient requests a visit of this type but it is determined by the physician or advanced practice provider that a telemedicine visit is more appropriate given the patient complaints, the staff should communicate that the nature of the problem requires a telemedicine office visit. We recommend that scheduling staff be well trained to communicate the differences and circumstances.

Other codes are available that are intended for encounters performed using a patient portal or other HIPAA-compliant communication method. Check with your insurers to see which codes may be covered.

 Medicare Advantage plans are expected to allow for coverage under Medicare guidelines or establish guidelines that are less stringent. In 2019, Medicare relaxed requirements for Medicare Advantage plans to be restricted to Medicare rules. Therefore, Medicare Advantage plans can offer more services or establish rules that provide additional services than those allowed for Medicare. Check payer websites for guidance. Some of these payers may allow telephone visits for established patients to be reported with established patient visit codes (99212-99215). Billing for Medicare Advantage plans should require only use of the appropriate CPT code with place of service 11 and modifier –95.

We have been following the Medicare Advantage plans, and in general most allow for coverage under the relaxed rules and have gone beyond Medicare to allow additional services to be provided remotely. Many payers have indicated that the patient co-payment for remote services will be covered by the payer, meaning the group will be paid the full allowed amount by the insurer.

 Medicaid programs are directed by the state. You will need to check with your state Medicaid program for coverage rules and billing for telemedicine and telehealth services. However, most states are relaxing requirements for remote services.

 Many commercial payer plans have policies that follow Medicare guidelines as they are published. With the emergency declaration, the larger payers have already released policies allowing for expanded coverage of both new and established office visits. Further, many of these payers are waiving patient responsibility for remote visits, promising to pay the full allowed amount for the encounters.

Some payers, in addition to using place of service 02, are requiring the use of modifier –95 (Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System: Synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the 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. Modifier 95 may only be appended to the services listed in Appendix P. Appendix P is the list of CPT codes for services that are typically performed face-to-face, but may be rendered via a real-time [synchronous] interactive audio and video telecommunications system.)

Some payers may require place of service 11 and modifier –GQ, –GT to report these services.

Telehealth is a viable tool to solve the continuity-of-care issues faced during the coronavirus restrictions. Patients appear to be adapting to and even liking the new format. We would encourage you to adopt HIPAA-compliant practices as soon as possible but use the relaxed enforcement declaration to take care of your patients in need. We are projecting that after the outbreak remote visits in the form of telehealth and telemedicine will remain an option for patient care.

As you move past the initial scramble to reschedule and retool your practice, develop protocols and policies that will allow you to adopt telehealth and telemedicine technologies for patient care under new policies that will likely fall somewhere between where they were and where they are for the crisis.

), American Association of Clinical Urologists (

), as well as regional and state urology associations

), Ambulatory Surgery Center Association (

 Centers for Medicare & Medicaid Services (

), Centers for Disease Control and Prevention (

 Physicians Reimbursement Systems Network (

"CMS has clarified that it will not enforce the requirement that remote services be reported only for patients with whom the physician has a prior relationship, allowing you to provide new patient visits remotely (99201-99205)," write Jonathan Rubenstein, MD, and Mark Painter.

Author | Jonathan Rubenstein, MD

Articles

It’s time to prepare for upcoming E/M coding changes

How to code for a perineal prostate biopsy

Coding for bladder scan raises several questions

How to code for urologic care during the COVID-19 pandemic