Successfully Report Medicare Telehealth Services
Get telehealth consultation work reimbursed by meeting CMS requirements.
Medicare payers haven’t recognized or reimbursed for CPT® consultation codes (99241-99245 outpatient and 99251-99255 inpatient) for more than five years, but the Centers for Medicare & Medicaid Services (CMS) does extend coverage to telehealth consultations, using dedicated G codes.
Codes describing initial telehealth consultations apply to inpatients, including those in a skilled nursing facility (SNF), or to patients in an emergency department (ED):
G0425 Telehealth consultation, emergency department or initial inpatient, typically 30 minutes communicating with the patient via telehealth [problem-focused history, problem-focused examination, straightforward medical decision making (MDM)]
G0426 Telehealth consultation, emergency department or initial inpatient, typically 50 minutes communicating with the patient via telehealth [detailed history, detailed examination, moderate complexity MDM]
G0427 Telehealth consultation, emergency department or initial inpatient, typically 70 minutes or more communicating with the patient via telehealth [comprehensive history, comprehensive examination, high complexity MDM]
Follow-up codes similarly apply to SNF or hospital inpatients, as well as to ED patients:
Follow-up inpatient consultation, limited, physicians typically spend 15 minutes communicating with the patient via telehealth [problem focused history, problem focused examination, straightforward MDM]
Follow-up inpatient consultation, intermediate, physicians typically spend 25 minutes communicating with the patient via telehealth [detailed history, detailed examination, moderate complexity MDM]
Follow-up inpatient consultation, complex, physicians typically spend 35 minutes communicating with the patient via telehealth [comprehensive history, comprehensive examination, high complexity MDM]
Per the Medicare Claims Processing Manual, chapter 12, section 190.3.1, subsequent hospital care services are limited to one telehealth visit every three days. Subsequent nursing facility care services are limited to one telehealth visit every 30 days.
Whether reporting initial or follow-up services, the provider must meet all three required elements (history, exam, MDM) to bill a particular level of service. For example, to report G0407, the provider must document at least a comprehensive history, a compressive exam, and high complexity MDM. The “lowest” of the three key components determines the billable level of service.
In another example, the provider performs an initial telehealth consult for an SNF patient and documents a comprehensive history, a detailed exam, and high complexity MDM. In this case, the exam is the lowest of the key components, which supports G0426.
Documentation Must Meet Consult Requirements
CMS defines a consultation as “an evaluation and management (E/M) service furnished to evaluate and possibly treat a patient’s problem(s). … The intent of an inpatient or emergency department telehealth consultation service is that a physician or qualified NPP or other appropriate source is asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, or counsel, etc. in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional’s knowledge.”
To demonstrate the service matches CMS’ definition of a consult, documentation should verify the following elements:
1. A request for opinion or advice, and a stated reason to substantiate the need for the service. Per the Medicare Claims Processing Manual, section 190.3.1:
A request for an inpatient or emergency department telehealth consultation from an appropriate source and the need for an inpatient or emergency department telehealth consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patient’s medical record and included in the requesting physician or qualified NPP’s plan of care in the patient’s medical record …
Because the consulting provider bills the service, it’s in his or her best interest to document the request as part of the patient record. Specify that the visit is a “consult” (not, for instance, a “referral,” which may signify to the payer a transfer of care rather than a request for a consultation). If possible, ask the requesting provider to put it in writing (email, fax, a note sent with the patient, etc.), and make that part of the record, too.
2. A report from the consulting provider back to the requesting provider. Section 190.3.1 specifies:
After the inpatient or emergency department telehealth consultation is provided, the consultant shall prepare a written report of his/her findings and recommendations, which shall be provided to the referring physician.
The service is justified only if the consulting physician gives his opinion and/or advice to the requesting provider. Without a report back to the requesting provider, a consultation hasn’t occurred.
The Patient Must Be in a Qualified Originating Site
Telehealth services are available only to patients in a qualified originating site. An originating site is defined as, “the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs.”
Telehealth originating sites must be located in a designated rural health professional shortage area (HPSA), located either outside of a metropolitan statistical area (MSA) or in a rural census tract, or a county outside of a MSA. To determine a potential originating site’s eligibility for Medicare telehealth payment, visit the CMS website: www.cms.gov/Medicare/Medicare- General-Information/Telehealth.
Note that a telehealth facility fee is paid to the originating site. You may submit claims for the facility fee using HCPCS Level II code Q3014 Telehealth originating site facility fee.
A Modifier Seals the Deal
Medicare pays only for interactive video consultation services that mimic face-to-face interactions between patients and providers. CMS stipulates that video telecommunications system must permit “real-time communication between … the physician or practitioner at the distant site, and the beneficiary, at the originating site.”
When reporting an approved telehealth service, you must append modifier GT Via interactive audio and video telecommunications systems to the appropriate service code(s). The modifier tells your Medicare contractor that the beneficiary was present at an eligible originating site when the telehealth service was furnished.
For example, for a comprehensive, initial consultation for a hospital inpatient in a HPSA, report G0427-GT.
“Asynchronous ‘store and forward’ technology” (e.g., video clips, still images, X-rays, magnetic resonance images, electrocardiograms and electroencephalograms, laboratory results, audio clips, and text) is covered only in federal telemedicine demonstration programs in Alaska or Hawaii. In cases when you may bill Medicare for “non-face-to-face” telehealth services, report the appropriate code for the professional service with modifier GQ Via asynchronous telecommunications system. In all other cases, as a condition of payment, the patient must be present and participating in the telehealth visit.
G.J. Verhovshek, MA, CPC, is managing editor at AAPC and a member of the Ashville-Hendersonville,
North Carolina, local chapter.
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