Coding for remote antenatal surveillance procedures during COVID-19.
The Society for Maternal-Fetal Medicine (SMFM) Coding Committee; Steve Rad, MD; Trisha Malisch, CCS-P, CPC; Vanita Jain, MD
The SMFM Coding Committee has recently published coding guidance for ICD-10-CM coding and Telemedicine for COVID-19 and pregnancy (https://www.smfm.org/covid19). Due to recent concerns about decreasing exposure and social distancing mandates during the pandemic, in addition to engaging more often in telemedicine services, some MFM subspecialists may also find themselves more frequently performing remote reading, interpretation, and reporting of ultrasound and other antenatal surveillance procedures.
The purpose of this document is to provide maternal-fetal medicine subspecialists interim coding guidance for remote reading, interpretation, and reporting of ultrasound and other antenatal surveillance procedures during the COVID-19 pandemic. Due to the rapid and ongoing changes during the pandemic, coding guidance may be subject to change.
Remote reading, interpretation and reporting:
When considering this topic, it is important to understand that there are 3 basic levels of supervision requirements for each CPT code as defined by a numerical indicator found in the "Physician Supervision of Diagnostic Procedures" column of the National Physician Fee Schedule Relative Value File, available at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html). Supervision indicators pertinent to diagnostic ultrasound procedures are as follows:
"1” - Procedure must be performed under general supervision. General supervision means the procedure or service is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure.
“2” - Procedure must be performed under direct supervision. Direct supervision generally means to be physically present, or within an immediate distance, such as on the same floor, and available to respond to the needs of something or someone. If billed, these studies cannot be interpreted remotely while away on travel.
“3” - Procedure must be performed under personal supervision. Personal supervision is defined as the physician must be in attendance in the room during the performance of the service or procedure.
“9” - Concept does not apply.
Most but not all obstetrical ultrasound procedures fall under the general supervision category and could be read remotely if appropriate local arrangements are made to inform the patient of her ultrasound results. Studies requiring direct or personal supervision cannot be interpreted or billed while away on travel. CMS does not give specific advice or examples of appropriate documentation. We recommend that for those services requiring personal supervision, the physician should document his/her presence during the study.
When reading remotely, it still holds that all components of the CPT study are included and the appropriate indication(s) used. An appropriate and complete report should similarly be generated and sent to the referring provider. Relaying the results of the study to the patient are part of the RVU work associated with the CPT so there should be a mechanism in place to relay the findings to the patient. While test results are not required to be conveyed to the patient in person, because of the expertise required for some scans, best practice is to have a physician available to discuss results with the patient. However, it is important to note, that informing the patient of normal ultrasound results is part of the CPT work associated with the ultrasound procedure and a separate Evaluation and Management (E/M) service cannot be billed to convey normal results (whether done in person or via telemedicine). E/M services done on the same day for counseling regarding abnormal results or for a separately indicated consultation, may be billed in addition to the ultrasound procedure, as long as all criteria have been met for the E/M charge and the content of the E/M has to be separately document. For additional information on telemedicine billing during the pandemic, please see the SMFM Coding Committee COVID-19 Telemedicine White Paper (https://www.smfm.org/covid19).
When reading studies remotely, appropriate use of modifiers 26 (professional component), TC (technical component), and 25 still apply. For example, if a facility performs a test, such as ultrasound, that a physician interprets, the physician bills the procedure code for that service with modifier 26, and the facility bills the same procedure code with modifier TC if this separation is applicable. Furthermore, modifier 25 is used to report a separate Evaluation and Management (E/M) service on a day when another service was provided to the patient by the same physician. In addition, if E/M services are rendered via telemedicine, additional place of service (02 telehealth) and use of modifier (95) is generally indicated but payor specific (see separate telemedicine guidance, https://www.smfm.org/covid19)
Example Scenarios
1. Physician remotely reads and interprets a detailed fetal anatomic survey for the indication of suspected anomaly, with normal findings. The physician relays normal results to the patient via telemedicine. No additional consult is performed. The physician generates a complete report for the study. Recommended coding: 76811. Modifier 26 would be used if applicable. The place of service would be the place of service where the scan was performed. Additional E/M not billed as only normal results were conveyed to the patient.
2. Physician remotely reads and interprets a 3rd trimester fetal growth ultrasound done for the indication of suspected IUGR; the patient is established, and previously had a normal second trimester detailed fetal anatomic survey performed by the same physician group. IUGR is noted with abnormal Umbilical Artery Doppler studies. BPP without NST is normal. The physician performs 15 minutes of face to face consultation via telemedicine to discuss these abnormal results and provides counseling and coordination of care for next steps and follow up. The physician generates a complete report for the study. Recommended coding: 76805, 76820, 76819, 99213.
E/M via telehealth: Modifiers 95 and 25 are applied as appropriate, and place of service 02 for telehealth is used.
Ultrasound studies: Modifier 26 is used for professional component of the diagnostic studies. The place of service for 76805, 76820, 76819 would be the place of service where the scan was performed. The telehealth place of service would not be applicable for remote interpretation of ultrasound or other diagnostic services.