Ms. Hester is Content Specialist with Contemporary OB/GYN and Contemporary Pediatrics.

Miranda Hester

Following the start of the pandemic in March 2020, telehealth services have been a key way to keep money coming into the practice, making knowing how to accurately and appropriately code more important than ever. 

Renee Slade, MD, FAAP, assistant professor of pediatrics at Rush University Medical College in Oak Park, Illinois, offered an overview for coding a variety of telehealth services at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition. She emphasized that all of the coding presented in her presentation was subject to change and to verify with up-to-date resources.

Although uptake of telehealth was slow prior to the pandemic, many studies have shown positive outcomes for its use including high satisfaction for both clinician and patient; overall convenience; a reduction in visits to the emergency department; and effective for the management of many chronic conditions. 

Since the start of the pandemic, Slade noted that she had experiences that led to better care, reduction in exposure to infectious diseases, and the ability to educate parents of safety.

For the purposes of the presentation, telehealth referred to any visit that used communication technology in lieu of a face-to-face visit. 

Telemedicine was used for any real-time synchronous video visit, which might also be called a virtual face-to-face visit. Telephone visits were any synchronous visits carried out via telephone. Digital visits were nonsynchronous and carried out through patient portals or secure email.

Current procedure terminology (CPT) codes for telemedicine visits have existed since 2017. Codes for telemedicine can be found in appendix P of the CPT manual. Commonly used codes for telemedicine include those used for office & outpatient evaluation and management (E/M) visits (99202-99215, 99417), subsequent hospital care (99231-99233), inpatient consultation (99251-99255), outpatient consultation (99241-99245), and others. 

The modifier 95 should be added to all codes used for telemedicine service. The place of service code should be 02, unless a payer prefers using the site of the clinician, where 11 for office or 22 for outpatient hospital facility would be used. Slade stressed that knowing and understanding payers’ policies would prevent future coding headaches.

Telephone visits can be used for established relationships. Practices should create an outgoing message that sets patient expectations about who will be calling back and when a return call may occur. They must be started by the patient and can only be used for a visit with a health problem. Clinicians should document the length of the call as that is the only determinant of the correct code. 

Codes for telephone visits can only be submitted by a physician or qualified health professional. The visit cannot be from an E/M service in the past 7 days or leading to an E/M service in the next 24 hours or next available appointment. If this is the case, the time of the telephone call should be combined with the face-to-face visit time, when submitting according to time. The CPT codes are 99441 (visit of 5-10 minutes duration), 99442 (visit of 11-20 minutes duration), and 99443 (visit of 21-30 minutes duration).

Digital visits are only for established visits and the service is cumulative over 7 days, with the clock starting when the physician reviews the patient inquiry. Only time spent on the visit by a physician or qualified health professional can be counted. The visit can’t be reported if less than 5 minutes is spent on it, occurs during the global period of a procedure, or is E/M linked to the same problem with 7 days of a telemedicine or face-to-face visit, although the time can be added in, if billing is based on time. 

An unrelated incident in that 7 day window can be reported as a separate visit. Clinicians should follow payer guidance on coding, with some requiring the XU modifier. Codes are 99421 (digital visit with cumulative 5-10 minutes), 99422 (digital visit with cumulative 11- 20 minutes), and 99423 (digital visit with cumulative 22+ minutes).

This article was originally published on Contemporary Pediatrics®. 

1. Slade R. Coding for virtual, digital, and telehealth services. American Academy of Pediatrics 2021 National Conference & Exhibition; virtual. Accessed October 9, 2021.

Articles

Telehealth has become increasingly popular as a result of the pandemic, which makes accurate coding for such visits more important than ever. A session at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition covers appropriate coding.

Telehealth coding tips

The onset of the adolescent years also means the need to discuss a variety of topics on sexual health such as sexually transmitted infections (STIs), pregnancy, and contraceptives. 

At a session at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition, Maria Trent, MD, MPH, FAAP, FSAHM, chief of the division of adolescent and young adult medicine at Johns Hopkins School of Medicine and Public Health in Baltimore, Maryland, discussed the importance of discussing sexual health with teenagers, how the pandemic changed the landscape, and what telehealth can bring to the plate.

For teenagers, the development of healthy sexuality is an important milestone on the path to being an adult. Parents are an important part of this and should be a part of the discussion. Research has found that high-quality discussions between parent and teenager about sexual health can lead to delays the first sexual experience; make the teenager more likely to discuss STIs and pregnancy with partners; use contraceptives; and have used condoms during his or her last sexual experience. 

Such discussions are becoming more common, but both parents and teenagers express feelings of discomfort and many adolescents feel embarrassed discussing the topic with their parents. Many parents and teenagers rely on their pediatrician to have discussions and most visits do have some type of sexual health content, but the average time spent is 36 seconds and only half of teenagers get time to speak to their provider alone.

The COVID-19 pandemic led to another wrinkle. Social distancing may have been a key way to prevent spread of the disease, but information indicates that many teenagers and young adults still engaged in sexual activity. Many medical offices were closed to in-person visits in the beginning months and public health departments that would’ve worked with sexual health were often shifted over to perform COVID-19 testing. 

Reduced access to care introduced new barriers to accessing contraceptives; preventive visits, which reduced the chance to provide anticipatory guidance; providing pregnancy options and counseling; counseling on risk reduction; and STI/HIV screening and treatment.

Telehealth is an important way to give vital sexual health care to adolescents. Some of the key parts of care that can be provided through it include anticipatory guidance, contraception counseling, family planning, coordinating follow-up care, and connecting teenagers to other resources. 

It also offers clinicians and teenagers a chance to have a private and confidential conversation about a variety of topics on sexual health. When visiting with an adolescent patient in the office, clinicians should be sure to tell them that telehealth is an option to discuss topics of a sexual nature. 

When in a Telehealth visit, health care professionals should ensure that the “tone” of the visit is the same as it would be in the office. Due to the sensitive nature of the topics discussed, clinicians should take a variety of steps to ensure that the adolescent patient’s confidentiality is maintained:

Inform the patient what confidentiality means and the limits that may exist for that confidentiality

Be aware of who is in the room with the patient

Help the teenager find a space that’s as private as possible, which may take some creativity

Encourage the teenager to use headphones during the visit

During telehealth visits, clinicians should be sure to discuss sexual health with all patients, not just female patients. Motivational interviewing can be a good way to encourage proactive and protective behaviors. 

If a hybrid visit requiring the patient to come into the office for other elements such as testing, clinicians should offer support as needed and ensure that the patient can get to the office for it.

1. Trent M. Meeting teens where they are: using telemedicine to improve sexual health. American Academy of Pediatrics 2021 National Conference & Exhibition; virtual. Accessed October 11, 2021.

Telehealth offers a whole new way to reach out to adolescent patients for critical conversations on sexual health, according to a session at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition.

Using telehealth to counsel teens on sexual health

Much like a person’s pulse rate, body temperature, respiration rate and blood pressure, menstruation can serve as a vital sign of a girl’s health and menstrual issues can indicate underlying health concerns. At the virtual 2021 American Academy of Pediatrics National Conference & Exhibition, Selma F. Witchel, MD, FAAP, professor of pediatrics at UPMC Children’s Hospital of Pittsburgh in Pennsylvania discussed the difference between normal and abnormal menses, the available toolbox, common irregular menses situations, and what to consider with menses in special populations.

The median age at menarche is 12.43 years. Normal menarche has a flow length of ≤7 days and typical product use is 3 to 6 pads or tampons a day. The cycle interval is irregular during the first gynecologic year; 21-45 days during the second gynecologic year; and 21-35 days from third gynecologic year until menopause. Signs of abnormal menses include menses lasting more than 7 days; initially regular menses becoming irregular; menses requiring pad/tampon changes every 1-2 hours and throughout the night; no menses by age 15 years with appropriate pubertal development; and no menses within 3 years of the onset of breast development.

Therapies available in the toolbox to use with menstrual disorders include combined oral contraceptives, the vaginal ring, depot medroxyprogesterone acetate, progestin-containing intrauterine devices, gonadotropin-releasing hormone (GnRH)-superagonists, and etronogestrel subnormal implants. Witchel noted that providers should be aware of whether treatments could impact bone mineral density during such a pivotal time, like combined oral contraceptives that have a mild negative impact or depot medroxyprogesterone acetate that has a significant adverse effect, or carry a risk of venous thromboembolism, such as combined oral contraceptives.

Witchel then discussed common irregular menstrual concerns including:

Menses too early - A cause of early menstruation is precocious puberty, which can be either GnRH-dependent, which can be idiopathic, genetic, or tied to central nervous system, or GnRH-independent, which can be the result of Prader-Willi syndrome, Williams and Temple syndrome, autonomous ovarian cysts, etc. A GnRH agonist can be used in the former. Isolated vaginal bleeding with no other signs of puberty is a diagnosis of exclusion and can be the result of sexual abuse, infection, vaginal foreign body, ovarian cyst, hypothyroidism, or pinworm endometritis.

Minimal breast development and delayed menses - Turner syndrome may be the cause in girls with short stature, cubitus valgus, shortened fourth metacarpals, short neck, high arched palate, neurosensory hearing loss, scoliosis, and Madelung deformity. It should be treated with growth hormone.

Secondary amenorrhea - Stress, pregnancy, traumatic brain injury, eating disorders, and diabetes can all lead to secondary amenorrhea. Polycystic ovary syndrome (PCOS) is another cause and can be treated with lifestyle modification, combined oral contraceptives, and metformin when needed. Witchel stated that an accurate evaluation of PCOS can’t be done if the patient already using oral contraceptives. Furthermore, care should be taken when diagnosing PCOS in teenage girls. Other disorders should excluded before doing so and certain diagnostic criteria such as insulin resistance and hyperinsulinemia should only be used with adult women.

Breast development and no menses - Causes can include androgen insensitivity, anatomical anomalies, or Mayer-Rokitansky-Kuster-Hauser syndrome, which may require surgical interventions.

Heavy menstrual bleeding - Bleeding disorders, PCOS, infection, thyroid disease, and hemorrhagic ovarian cysts can all cause heavy menstrual bleeding. Bleeding disorders should be considered if there is a family history, menorrhagia since menarche, or a personal history of bleeding episodes. Treatment includes acute and maintenance therapies from the toolbox.

The session ended with Witchel discussing menstruation in adolescent girls with disabilities. She noted that menstrual management or suppression is often desired by this group. Providers should engage in shared decision-making when possible. Some physical disabilities may make some forms of menstrual hygiene more difficult or undesirable. Some medications may cause hyperprolactinemia and interactions may occur between some seizure medications and sex steroids. A hysterectomy is not considered appropriate management in this group. If it’s being considered as a last resort, Witchel recommended a consult with an ethics committee.

1. Witchel S. Evaluation and management of menstrual disorders in teens. American Academy of Pediatrics 2021 National Conference & Exhibition; virtual. Accessed October 8, 2021.

A session at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition highlights menstrual disorders in adolescent girls.

Diagnosing and managing menstrual disorders in teen girls

Following a review by the US Food and Drug Administration, the infant nutrition product 

 is meant to be used under medical supervision and will be available to clinicians and registered dieticians by the end of September 2021.1 The formula is meant to support catch-up growth in term infants with growth failure or who are at risk of it as well as those who require more energy or have fluid restrictions.

The formula can be used in infants and toddlers up to age 18 months. The formula has 30 calories per fluid ounce and is the first created to feed infants with undernutrition or failure to thrive. The benefits of the Fortini™ have been supported by 7 clinical trials and a retrospective chart review. In those clinical trials, the formula was shown to be well tolerated by infants and toddlers. To achieve higher caloric density previously, clinicians have often had to recommend special recipes to parents that either involved increased amounts of powdered formula or liquid fats, which carried a risk of mixing errors, unbalanced nutrition, and poor tolerance of the over-concentration of formula.

Nutricia hopes to have the formula available for recommendation to families who qualify for either Medicaid or the Special Supplemental Nutrition Program for Women, Infants, and Children within the year following the product’s launch.

1. Nutricia. Fortini™ infant formula clears FDA review; energy- and nutrient-dense formula aims to set new standard in US to support growth in infants with, or at risk of, failure to thrive. Published September 23, 2021. Accessed September 29, 2021. 

https://www.prnewswire.com/news-releases/fortini-infant-formula-clears-fda-review-energy--and-nutrient-dense-formula-aims-to-set-new-standard-in-us-to-support-growth-in-infants-with-or-at-risk-of-failure-to-thrive-301381341.html

 article was originally posted on Contemporary Pediatrics®.

The US Food and Drug Administration (FDA) has cleared Fortini™, a formula meant for the nutritional needs of term infants with failure to thrive.

FDA approves Fortini™ formula for term infants  with failure to thrive

For many who have become ill with COVID-19 and recovered, all that remains is natural immunity. However, for others, “long COVID” becomes a fact of life, leaving many with fatigue, shortness of breath, “brain fog,” depression, and other symptoms. To study this condition, the National Institutes of Health has 

 the REsearching COVID to Enhance Recovery (RECOVER) Initiative and awarded roughly $470 million to create a national study population of diverse volunteers as well as support large-scale studies on long-term effects of COVID-19.1 The funding is supported by the American Rescue Plan.

The research will include children, adults, and pregnant people, who have been enrolled either during the acute or post-acute phases of infection. It is expected to look at incidence and prevalence of long COVID, symptoms, underlying causes, risk factors for having lingering symptoms, and outcomes. Data from the initiative’s cohort is expected to include clinical information, laboratory tests, and analyses of participants who were in various stages of recovery following infection. Access to this information is expected to help accelerate research.

In the press release for the program, Walter J. Koroshetz, MD, director of National Institutes of Health’s National Institute of Neurological Disorders and Stroke as well as one of the RECOVER co-chairs said, “given the range of symptoms that have been reported, intensive research using all available tools is necessary to understand what happens to stall recovery from this terrible virus. Importantly, the tissue pathology studies in RECOVER will enable in depth studies of the virus’s effects on all body systems.”

This article was originally posted on Contemporary Pediatrics®.

1.National Institutes of Health. NIH builds large nationwide study population of tens of thousands to support research on long-term effects of COVID-19. Published September 15, 2021. Accessed September 15, 2021. 

https://www.nih.gov/news-events/news-releases/nih-builds-large-nationwide-study-population-tens-thousands-support-research-long-term-effects-covid-19

Long COVID remains a mystery, more than a year after the condition first arose. To find answers, the National Institutes of Health (NIH) has created a research initiative, awarding grants totaling roughly $470 million.

NIH awards $470 million to long COVID research

Research over the past several years has shown that a variety of health outcomes vary by race or ethnicity, which has led to government agencies declaring that institutional racism is a public health crisis. A 

 on neonatal morbidity elucidates the differences noted between White infants and their non-White counterparts.1

Investigators used birth certificate and discharge abstract data from 40 New York City hospitals from 2010–2014. Newborns were included if they were born at term, singleton, had a birth weight ≥2500 g, and were without preexisting fetal conditions. Morbidity was classified using The Joint Commission’s unexpected newborn complications metric. Multivariable logistic regression was used to compare the morbidity risk among ethnic and racial groups. Risk-standardized complication rates were created for each hospital to examine quality and allow for ranking, as well as assessing the differences in the racial and ethnic distribution of births across the facilities.

Among the 483,834 low-risk infants, the unexpected complications rate was 48.0 per 1000 births. Following adjustment for patient characteristics, investigators found that the risk of morbidity was higher among Black and Hispanic infants than White infants (odds ratio: 1.5 [95% CI 1.3–1.9]; odds ratio: 1.2 [95% CI 1.1–1.4], respectively). Among the 40 hospitals included in the sample, the risk-standardized complications varied from 25.3 to 162.8 per 1000 births. One in 3 Black and Hispanic women delivered their child in a hospital that ranked in the highest morbidity category. By comparison, 1 in 10 White and Asian American women delivered in a hospital in that category (

The investigators concluded that Black and Hispanic women were far more likely to deliver a child in a hospital that had high complication rates than women who were White or Asian American. They noted that the results of their study connect hospital quality with newborn health disparities that are preventable. The creation of quality improvement programs that address routine obstetric and neonatal care in hospitals is paramount to achieving equity in perinatal outcomes for Black and Hispanic outcomes.

This article was originally posted on Contemporary Pediatrics®. 

1. Glazer K, Zeitlin J, Egorova N, et al. hospital quality of care and racial and ethnic disparities in unexpected newborn complications. 

. August 24, 2021. Epub ahead of print. doi:10.1542/peds.2020-024091

Racial disparities abound in health care. How do they impact neonatal morbidity?