Coding for telehealth

Coding for telehealth

Many payers, including Medicare, provided coverage for telehealth services prior to the COVID-19 public health emergency (PHE). Over the past two years, there has been a dramatic increase in the use of telehealth services for both physical and mental health concerns. Telehealth/telemedicine is typically defined as two-way, real-time audio and visual communication with a patient, usually via a telehealth portal or platform.

During the COVID-19 PHE, Medicare, private payers, and many states waived certain coverage requirements. Check with your state medical association for details.

This article focuses primarily on Medicare coverage policies. Many of the telehealth coverage waivers were set to expire at the end of the COVID-19 PHE or at the end of the calendar year when the PHE for COVID-19 ends. This spring, the Consolidated Appropriations Act (CAA) of 2022 was signed into law, which extends certain Medicare telehealth flexibilities for a period beyond the end of the PHE.

Coding for telemedicine services varies among carriers and Medicare. We suggest you obtain verification of benefits on telemedicine just like any other service; a verification sheet may be helpful. Unfortunately, coverage also varies from policy to policy, so, for example, one Blue Cross policy may cover telemedicine while another will not.

Medicare Coverage During the PHE

  • Audio only phone calls: Medicare generally requires telehealth visits to use both audio and visual technology; however, this requirement is currently waived to allow Medicare payment when the physician provides audio-only visits. Medicare will now pay for audio-only phone calls using existing CPT Codes 99441-443 (for clinicians) and 98966-68 for clinical staff. The code selection is based on time. Reimbursement ranges from about $14 to $41. The CAA extended Medicare coverage of audio-only services for 151 days after the end of the PHE.
  • Nonfacility rate for telehealth evaluation and management (E/M): Medicare will pay the higher nonfacility rate for E/M telehealth visits during the COVID-19 PHE – for all telehealth services, not just those related to COVID-19. This policy is retroactive to March 1, 2020. As a result, physician claims should use the place of service (POS) code that would apply if the services were provided in person (POS 11 for a physician office) and should not use the telehealth POS code 2. They should use modifier 95 to indicate the service was provided via telehealth. After the PHE, physicians will likely go back to using POS code “02” for telehealth services. However, last fall, CMS issued guidance updating the current POS code set by revising the description of existing POS code 02 and adding new POS code 10. The codes are revised as follows:
    • POS 02: Telehealth Provided Other Than in Patient’s Home Descriptor: The location where health services and health related services are provided or received, through telecommunication technology. Patient is not located in their home when receiving health services or health related services through telecommunication technology.
    • POS 10: Telehealth Provided in Patient’s Home Descriptor: The location where health services and health related services are provided or received through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology.

    The guidance states that “Medicare hasn’t identified a need for new POS code 10.” Physicians will want to confirm with their Medicare MAC regarding whether it should use the POS code 10 after the end of PHE. Certain commercial providers require use of the POS code 10 for telehealth services provided in the patient’s home (e.g., Anthem and UnitedHealthcare).

  • E/M Coding: When billing for an E/M service provided via telehealth for the duration of the PHE, the physician should use the same CPT Code used if the service was provided in person, but with one exception: Medicare will now allow telehealth visits to be coded based on complexity of medical decision-making or time, regardless of whether counselling and coordination of care comprise 50% of the visit. This is similar to the policy that went into effect on Jan. 1, 2021 for all E/M services. CMS also waived its rule allowing care for established and new patients.
  • Supervision of Incident-to Services: The direct supervision (i.e., on-site) requirement for Medicare incident-to services and for certain diagnostic tests can be performed via audio/visual real time communications technology. This relaxed direct supervision requirement will remain in effect through the end of the calendar year in which the PHE for COVID-19 ends.
  • Expansion of covered telehealth services: CMS is allowing physicians to reduce or waive cost sharing for telehealth visits. CMS will also allow physicians licensed in one state to provide services to Medicare beneficiaries in another state. State licensure laws still apply, so you should consult the requirements of the state licensing board where the patient is located. CMS has also added coverage for a series of new CPT Codes that can be furnished via telehealth. The codes and an in-depth discussion of the codes, their criteria and CMS reasoning are available in the interim final rule.
  • For telehealth services furnished during the COVID-19 PHE, CMS is allowing clinicians to use the POS code they would have otherwise reported had the service been furnished in person. To identify these services as Medicare telehealth, CMS is requiring that modifier 95 be appended to the claim. CMS is only requiring the CR modifier on certain telehealth services during the COVID-19 PHE (see MLN SE20011). Additionally, consistent with current rules for telehealth services, there are three scenarios where modifiers are required on Medicare telehealth professional claims:
    • Furnished as part of a federal telemedicine demonstration project in Alaska and Hawaii using asynchronous (store and forward) technology – use GQ modifier.
    • Furnished for diagnosis and treatment of an acute stroke – use G0 modifier.
    • Billed under CAH Method II.
  • Services provided in the patient’s home: Prior to the start of the COVID-19 PHE, the Medicare statute restricted the telehealth services that could be provided when the originating site was the patient’s home. CMS waived the originating site requirement for telehealth services, allowing providers to receive Medicare payment for delivering telehealth services to patients at home. The CAA extended this flexibility for 151 days after the end of the PHE.

ICD-10 codes should be related to the reason for the call or online interaction. The AMA has developed a series of coding scenarios on telehealth you may find helpful. The revised version has a red box in the upper right corner stating: Updated September 20, 2021.

Telehealth Modalities and Cost Sharing
Interactive telecommunications system means multimedia communications equipment that includes, at a minimum, audio and/or audio-video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner.

For the duration of the public health emergency, the HHS Office for Civil Rights (OCR) is exercising enforcement discretion and waiving penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communication technologies, such as FaceTime or Skype.

Depending on the state, parity laws – where insurance companies are required to pay telemedicine at the same rate as an in-office visit – may vary.

There are a number of other technology-based communication services short of a telehealth encounter that provide opportunities for patients to confer with and get advice from their physician.

  • Digital e-visits: patient initiated, non-face-to-face services through a secure patient portal (the patient must verbally consent to receive virtual check-in services). These are typically electronic (or secure email) services.
    • For the duration of the PHE, clinicians can bill using CPT Codes 99421-99423.
    • If the communication is performed by clinical staff (e.g., a registered nurse), Medicare requires the use of G codes G2061-G2063; third-party payers use 98970-98972.
  • Evaluation of a recorded image or video: sent by a patient for evaluation and billed using G2010. The “store and forward” service must not arise from a service within the past seven days or result in a service in the next 24 hours or next available appointment.
  • Virtual check-in services:
    • During the COVID-19 PHE, CMS established HCPCS code G2252 to allow for a provider to furnish a longer virtual check-in, in any form of synchronous communications technology, including audio-only, on an interim basis for CY 2021. G2252 is defined as a “brief communication technology-based service, e.g., virtual check-in service, by physician or other qualified health care professional who can report E/M services, provided to an established patient, not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment, 11-20 minutes of medical discussion.” CMS finalized the proposal to permanently establish HCPCS code G2252 under the 2021 Physician Fee Schedule.

The Advocacy Council knows that for many of its members, telemedicine has become an important part of their practices.