Online Digital Evaluation e-visits

Guidelines

• Online digital evaluation and management (E/M) services (99421, 99422, 99423) are patient-initiated services with physicians or other qualified health care professionals (QHPs). 

• It requires a physician or other QHP's evaluation, assessment, and management of the patient. 

• These services are not for the nonevaluative electronic communication of test results, scheduling of appointments, or other communication that does not include E/M. 

• While the patient's problem may be new to the physician or other QHP, the patient is an established patient. 

• Patients initiate these services through Health Insurance Portability and Accountability Act (HIPAA)-compliant secure platforms, such as electronic health record (EHR) portals, secure email, or other digital applications, which allow digital communication with the physician or other QHP.

• Online digital E/M services are reported once for the physician's or other QHP's cumulative time devoted to the service during a seven-day period. 

• Physician's or other QHP's cumulative service time includes a review, Initial inquiry,  review of patient records or data pertinent to an assessment of the patient's problem, 

• The personal physician or other QHP interaction with clinical staff focused, the patient's problem, development of management plans, 

• Including physician- or other QHP generation of prescriptions or ordering of tests, and subsequent communication with the patient through online, telephone, email, or other digitally supported communication, which does not otherwise represent a separately reported E/M service. 

• When the online digital inquiry is related to a surgical procedure and occurs during the postoperative period of a previously completed procedure, then the online digital E/M service is not reported separately. 

• When the patient generates the initial online digital inquiry for a new problem within seven days of a previous E/M visit that addressed a different problem, then the online digital E/M service may be reported separately. 

• When the patient presents a new, unrelated problem during the seven-day period of an online digital E/M service, then the physician's or other QHP's time spent on evaluation, assessment, and management of the additional problem is added to the cumulative service time of the online digital E/M service for that seven-day period.

Physicians

• CPT 99421 - Online digital evaluation and management service, for an established patient, for up to 7 days, a cumulative time during the 7 days; 5-10 minutes

• CPT 99422 - CPT 99421 - Online digital evaluation and management service, for an established patient, for up to 7 days, a cumulative time during the 7 days; 11-20 minutes

• CPT 99423 - CPT 99421 - Online digital evaluation and management service, for an established patient, for up to 7 days, a cumulative time during the 7 days; 21 or more minutes

Non-physicians (NP & PA)

• CPT 98970 - Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, a cumulative time during the 7 days; 5-10 minutes

• CPT 98971 - Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, a cumulative time during the 7 days; 11-20 minutes

• CPT 98972 - Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, a cumulative time during the 7 days; 21 OR more minutes

2021 E&M Changes

COVID - 19 Vaccine Updates - May'2021

The FDA is recommended to use "Pfizer-BioNTech" COVID-19 vaccine for adolescents aged 12-15 years.  

On May 12, 2021, the Advisory Committee on Immunization Practices (ACIP) recommended the use of the "Pfizer-BioNTech" COVID-19 vaccine in adolescents aged 12-15 years, and CDC Director Rochelle Walensky adopted this ACIP recommendation.

All COVID-19 vaccination providers are directed and required to make available and administer COVID-19 vaccine to all persons eligible to receive the COVID-19 vaccine consistent with the applicable Emergency Use Authorizations for such products.   

The COVID-19 vaccines themselves are free to everyone 12 years and older in the United States, but providers incur costs associated with administering them, training staff, and storing the vaccine. 

If these services are not covered by a patient’s health plan or only partially covered, providers are not allowed to balance bill the patients.

Claims for reimbursement will be priced as described below for eligible services,

Vaccine administration fees will be priced based on national Medicare rates for administering the COVID-19 vaccine (not geographically adjusted) and are outlined below,

For dates of service through March 14, 2021:-

• Administration of a single-dose COVID-19 vaccine - $28.39

• Administration of the first dose of a COVID-19 vaccine requiring a series of two or more doses - $16.94

• Administration of the final dose of a COVID-19 vaccine requiring a series of two or more doses - $28.39

For dates of service on or after March 15, 2021:-

• Administration (per dose) of a COVID-19 vaccine - $40.00

• Reimbursement will be based on the incurred date of service.

Click here for COVID-19 Lab Code Updates

Cognitive Assessment and Care Plan - Guidelines

Cognitive assessment and care plan services are provided when a comprehensive evaluation of a new or existing patient, who exhibits signs and/or symptoms of cognitive impairment, is required to establish or confirm a diagnosis, etiology, and severity for the condition.

Do not report cognitive assessment and care plan services if any of the required elements are not performed or are deemed unnecessary for the patient’s condition

A single physician or other qualified health care professional should not report 99483 more than once every 180 days.

CPT code 99483 provides reimbursement to physicians and other eligible billing practitioners for a comprehensive clinical visit that results in a written care plan

Eligible Provider

Any provider is eligible to report E/M services can provide this service. Eligible providers include physicians MD and DO, nurse practitioners, clinical nurse specialists, and physician assistants. 

Eligible practitioners must provide documentation that supports a moderate-to-high level of complexity in medical decision making, as defined by E/M guidelines.

The provider must also document the detailed care plan developed as a result of each required element covered by 99483

Required Elements to bill CPT 99483

CPT 99483 - Assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home, with all of the following required elements,

• Cognition-focused evaluation including a pertinent history and examination.

• Medical decision-making of moderate or high complexity.

• Functional assessment (eg, basic and instrumental activities of daily living), including decision-making capacity.

• Use of standardized instruments for the staging of dementia (eg, functional assessment staging test [FAST], clinical dementia rating [CDR]).

• Medication reconciliation and review for high-risk medications.

• Evaluation for neuropsychiatric and behavioral symptoms, including depression, including use of standardized screening instrument(s).

• Evaluation of safety (eg, home), including motor vehicle operation.

• Identification of caregiver(s), caregiver knowledge, caregiver needs, social supports, and the willingness of caregiver to take on caregiving tasks.

• Development, updating or revision, or review of an Advance Care Plan.

• Creation of a written care plan, including initial plans to address any neuropsychiatric symptoms, neurocognitive symptoms, functional limitations, and referral to community resources as needed (eg, rehabilitation services, adult day programs, support groups) shared with the patient and/or caregiver with initial education and support.

• Typically, 50 minutes are spent face-to-face with the patient and/or family or caregiver.

Many of the required assessment elements can be completed by appropriately trained members of the clinical team working with the eligible provider. 

Assessments that require the direct participation of a knowledgeable care partner or caregivers, such as a structured assessment of the patient’s functioning at home or a caregiver stress measure, may be completed prior to the clinical visit and provided to the clinician for inclusion in care planning. 

Care planning visits can be conducted in the office or other outpatient, home, domiciliary, or rest home settings.

Qualified health care professionals may report 99483 as frequently as once per 180 days

Tips

Do not report 99483 in conjunction with the following CPT codes,

• E/M services - 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99366, 99367, 99368, 99497, 99498.

• Psychiatric diagnostic procedures 90785, 90791, 90792.

• Brief emotional/behavioral assessment - 96127.

• Psychological or neuropsychological test administration 96146. 

• Health risk assessment administration 96160, 96161.

• Medication therapy management services 99605, 99606, 99607.

Click Here for Related Information

Cognitive Assessment & Care Plan - Provider's Education

The CMS to conduct provider outreach and education for the Medicare-covered Cognitive Assessment & Care Plan Services for CPT code 99483 to increase awareness of this service and its eligibility requirements.

The CMS sending education document, including a direct mailing, from the Medicare Administrative Contractors (MACs) to eligible clinicians. 

For about Medicare-covered Cognitive Assessment & Care Plan Services. The education and mailing will raise general awareness of the benefit and provide information on eligibility and billing.

Eligible Providers

• Physicians, 
• Nurse practitioners, 
• Clinical nurse specialists, 
• Certified nurse-midwives
• Physician assistants

Eligible Patients

• All beneficiaries who are cognitively impaired are eligible to receive the services under the code. 

• This includes those who have been diagnosed with Alzheimer’s, other dementias, or mild cognitive impairment. But, it also includes those individuals without a clinical diagnosis who, in the judgment of the clinician, are cognitively impaired.

Evaluation and Management services

• If a physician, or other clinicians eligible to bill Evaluation and Management services, finds a patient shows signs of cognitive impairment during a routine visit.

• Medicare covers a separate visit to more thoroughly assess the patient’s cognitive function and develops a care plan. 

• The cognitive assessment includes a detailed history and patient exam. There must be an independent historian for assessments and corresponding care plans provided under CPT code 99483.

Effective January 1, 2021, Medicare increased payment for these services, added these services to the definition of primary care services in the Medicare Shared Savings Program, and permanently allowed these services to be provided via telehealth.

Return to CCM

New Waived Tests for Labs - Modifier QW Updates

The Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations require a facility to be appropriately certified for each test performed. 

To ensure that Medicare & Medicaid only pay for laboratory tests categorized as waived complexity under CLIA in facilities with a CLIA certificate of waiver.

The listed below are the latest tests approved by the Food and Drug Administration (FDA) as waived tests under CLIA. 

The Current Procedural Terminology (CPT) codes for the following new tests must have the modifier QW to be recognized as a waived test. 

However, the below-mentioned tests did not require a QW modifier to be recognized as a waived test.

Example (i.e., CPT codes: 81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651) 

• 81002 - Dipstick or tablet reagent urinalysis – non-automated for bilirubin, glucose, hemoglobin, ketone, leukocytes, nitrite, pH, protein, specific gravity, and urobilinogen.

• 81025 - Urine pregnancy tests by visual color comparison.

• 82270 & 82272 - Fecal occult blood.

• 82962 - Blood glucose by glucose monitoring devices cleared by the FDA for home use.

• 83026 - Hemoglobin by copper sulfate – nonautomated.

• 84830 - Ovulation tests by visual color comparison for human luteinizing hormone.

• 85013 - Blood count; spun microhematocrit.

• 85651 - Erythrocyte sedimentation rate – nonautomated. 

The CPT code 80305 is required modifier QW, effective date, and description for the latest tests approved by the FDA as waived tests under CLIA is the following,

• August 25, 2020, Verify Diagnostics Inc. VeriCheck Drug Test Cup;

• August 25, 2020, Verify Diagnostics Inc. VeriCheck Drug Test Dip;

• September 23, 2020, Axium BioResearchInc.DrugExam Multi-Drug Screen Test;

• October 9, 2020, American Screening LLC Discover Panel Dip Card Tests MOR 300;

• October 9, 2020, American Screening LLC Discover Quick Cup Tests MOR 300;

• October 9, 2020, American Screening LLC Discover Quick Cup Tests MOR 2000;

• October 9, 2020, American Screening LLC Discover Plus Panel Dip Card Tests MOR 300;

• October 9, 2020, American Screening LLC Discover Plus Panel Dip Card Tests MOR 2000;

• October 9, 2020, American Screening LLC Discover Plus Quick Cup Tests MOR 300;

• October 9, 2020, American Screening LLC Discover Plus Quick Cup Tests MOR 2000;

• October 9, 2020, American Screening LLC OneScreen Plus Quick Cup Tests MOR300

• October 9, 2020, American Screening LLC OneScreen Plus Quick Cup Tests MOR2000;

• October 9, 2020, American Screening LLC Reveal Panel Dip Card Tests MOR2000;

• October 9, 2020, American Screening LLC Reveal Quick Cup Tests MOR300; and

• October 9, 2020, American Screening LLC Reveal Quick Cup Tests MOR2000.

Evaluation Management - New Patients Vs Established Patients

The E/M codes are categorized based on the service rendered in the setting and or location. 

Examples,

• Office or other outpatient setting 
• Emergency department (ED) 
• Hospital inpatient 
• Nursing facility (NF)

Patient Type 

For the billing purpose and the code selection will be depending on the service performed with the same physician either new patients or established patients. 

New Patient

An individual who did not receive any professional services from the physician and or other qualified healthcare professional or non-physician practitioner (NPP) or another physician of the same specialty and or sub specialty  who belongs to the same group practice within the previous 3 years

Established Patient

An individual who receives professional services from the physician or other qualified healthcare professional or non-physician practitioner (NPP) or another physician of the same specialty and or sub specialty who belongs to the same group practice within the previous 3 years.

Key Components 

The E/M codes are mostly selected based on three major key components to electing the appropriate level of E/M services

Major Key Components 

• History
• Examination
• Medical Decision Making (MDM)

Other Contributing Factors 

The E/M codes are rarely selected based on the Contributing Factors

• Counseling
• Coordination of care
• Nature of presenting problem
• Time.

2021 Changes

CPT code 99201 (new patient, level 1) deleted from Jan 1, 2021 and the CPT code 99211 l remain as a reportable service

The first two major key components of History and Physical Examination removed as key components for selecting the level of E&M service for office and or outpatient services (CPT 99202 to 99215).

In  before 2021, history and exam are two of the three components used to select the appropriate E&M service.

From Jan 2021, history and exam will no longer be used to select an E&M service for office and or outpatient visits, but still must be performed and documented in the medical record in order to selecting the appropriate CPT codes 99202-99215.

For 2021 E&M Changes

HRSA COVID-19 Coverage Assistance Fund and Rural Health Clinic (RHC) Payment Limits

HRSA COVID-19 Coverage Assistance Fund 

The Biden-Harris Administration is providing free access to COVID-19 vaccines for every adult living in the United States. 

Accordingly, the Health Resources and Services Administration’s (HRSA) COVID-19 Coverage Assistance Fund (CAF) will cover the costs of administering COVID-19 vaccines to patients whose health insurance doesn’t cover vaccine administration fees, or does but typically has patient cost-sharing. 

While patients cannot be billed directly for the COVID-19 vaccine fees, costs to health care providers on the front lines for administering COVID-19 vaccines to underinsured patients will now be fully covered through CAF, subject to available funding. 

As vaccination efforts accelerate, patients will increasingly gain access to COVID-19 vaccines at locations near where they live with providers they trust.

Providers are eligible for claims reimbursement if they have administered Food and Drug Administration (FDA) authorized COVID-19 vaccines under an Emergency Use Authorization (EUA) or FDA-licensed COVID-19 vaccines under a Biologics License Application (BLA) to individuals whose health plan does not cover vaccine administration fees, or does but typically has patient cost-sharing.

The eligible providers will be reimbursed at national Medicare rates for vaccine administration fees, and for any patient cost-sharing related to vaccination, including,

• Co-pays
• Deductibles,
• Co-insurance

Rural Health Clinic (RHC) Payment Limits

Effective January 1, 2021, the RHC payment limit per visit for Calendar Year (CY) 2021 is $87.52. This payment limit applies to independent RHCs and RHCs that are provider-based to a hospital with 50 or more beds.

Beginning April 1, 2021, the RHCs will begin to receive an increase in their payment limit per visit over an 8-year period, with a prescribed amount for each year from 2021, through 2028. 

Then, in subsequent years, the limit is updated by the percentage increase in MEI applicable to primary care services furnished as of the first day of that year.

The RHC payment limit per visit over an 8-year period is as follows,

• In 2021, after March 31, at $100 per visit
• In 2022, at $113 per visit
• In 2023, at $126 per visit
• In 2024, at $139 per visit
• In 2025, at $152 per visit
• In 2026, at $165 per visit
• In 2027, at $178 per visit
• In 2028, at $190 per visit