Stitch Together the Pieces of Telehealth Rules
Payers vary on documentation and coding requirements for telehealth services.
The rules for documenting and coding telehealth services are a patchwork. Guidelines for Medicare payers, although evolving, are well established. Private payer rules vary depending on the insurer, the patient’s individual plan, and the state where the services are rendered. Regardless of payer, you’ll need to go the extra mile to learn the requirements.
Medicare Spells Out Its Rules
National Medicare rules specify exactly which services may be provided via telehealth, who may provide the services, and which patients may benefit. The rules, summarized below, are well explained in the Medicare Learning Network, “Rural Health Fact Sheet Series: Telehealth Services.” (Telehealth Services Fact Sheet, May 3, 2017).
Codes: The Centers for Medicare & Medicaid Services (CMS) limits reimbursement for telehealth to those services represented by approximately 85 CPT® and HCPCS Level II codes. The list of Medicare-covered telehealth services is subject to change each year, and includes select psychotherapy services (90832-90838); end-stage renal disease services (90951-90952, 90954-90956); outpatient evaluation and management (E/M) services (99201-99215); advanced care planning (99497-99498); annual depression screening (G0444 Annual depression screening, 15 minutes), etc.
Eligible providers: Healthcare providers who may report telehealth services for Medicare patients include:
- Nurse practitioners
- Physician assistants
- Nurse midwives
- Clinical nurse specialists
- Registered dietitians or nutrition professionals
- Clinical psychologists (CP) and clinical social workers (CSW): however, CMS does not allow CPs and CSWs to bill Medicare for psychiatric diagnostic interview examinations with medical services or medical E/M services, which include:
90792 Psychiatric diagnostic evaluation with medical service;
+90833 Psychotherapy, 30 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure);
+90836 Psychotherapy, 45 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure); and
+90838 Psychotherapy, 60 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
Services billed must be within a practitioner’s scope of practice under applicable state law.
Patient location: The Medicare patient receiving the telehealth service must be in an approved originating site, which CMS defines as, “the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs.” The requirement has two parts:
1. Per CMS, “Beneficiaries are eligible for telehealth services only if they are presented from an originating site located in a rural Health Professional Shortage Area or in a county outside of a Metropolitan Statistical Area.”
A list of Health Professional Shortage Areas, by state and county, may be found on the U.S. Department of Health and Human Services Health Resources and Services Administration website (http://hpsafind.hrsa.gov). The U.S. Census maintains a list of Metropolitan Statistical Areas on its website (http://www.census.gov/population/metro/).
Entities that participated in a federal telehealth demonstration project prior to Jan. 1, 2001, qualify as originating sites, regardless of geographic location.
2. An originating site must be authorized by law, and may include:
Physician or practitioner offices
- Critical access hospitals (CAH)
- Rural health clinics (RHC)
- Federally qualified health centers (FQHC)
- Skilled nursing facilities (SNF)
- Community mental health centers (CMHC) hospital-based or CAH-based renal dialysis centers (including satellites) (independent renal dialysis facilities are not eligible originating sites)
Provider/Patient interaction: As a condition of payment for telehealth services, CMS requires that providers, “… must use an interactive audio and video telecommunications system that permits real-time communication between [the provider], at the distant site, and the beneficiary, at the originating site. Asynchronous ‘store and forward’ technology is permitted only in federal telemedicine demonstration programs in Alaska or Hawaii.”
In other words, the patient and provider must be in constant, two-way communication during the service.
Modifier requirement: When reporting an approved telehealth service, append modifier GT Via interactive audio and video telecommunications systems to the appropriate service code(s). For example, to bill a level 4 established patient office visit provided via telehealth, report 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity-GT. By appending the modifier, the provider is certifying that the beneficiary was present at an eligible originating site when the telehealth service was furnished.
Note that when appending modifier GT with a covered ESRD-related service telehealth code (e.g., 90951 End-stage renal disease (ESRD) related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face visits by a physician or other qualified health care professional per month), the provider also certifies that one visit per month was furnished “hands on” to examine the vascular access site, per the code descriptor requirement.
In those cases (limited to Alaska and Hawaii) when you may bill Medicare for non-face-to-face telehealth services, report the appropriate code for the professional service with modifier GQ Via an asynchronous telecommunications system.
Payment rates: Medicare pays telehealth services at the same rate as an identical service furnished without the use of a telecommunications system.
Private Payer Rules May Vary
Private payer guidelines to report telehealth services may depend on the laws within your state. Approximately 30 states (and the District of Columbia) have parity laws, which essentially require private insurers to pay for telehealth just as they would in-person care. Payers in states without parity laws may cover telehealth services (Aetna, Blue Cross Blue Shield, Humana, Cigna, and United Healthcare, for instance), although they are not legally required to do so. Even in states with parity laws, there may be exceptions for certain types of health plans (workers’ compensation, for instance, or small group plans). The disparity of telehealth coverage means you might have to determine patient eligibility on an individual, case-by-case basis.
As with coverage, coding and documentation requirements for telehealth vary by payer.
Codes/Modifier requirement: Some payers may want you to use telehealth-specific codes such as 99444 Online evaluation and management service provided by a physician or other qualified health care professional who may report an evaluation and management services provided to an established patient or guardian, not originating from a related E/M service provided within the previous 7 days, using the Internet or similar electronic communications network. Many advise you to report a standard E/M service code (e.g., 99201-99215), or other appropriate chronic care or mental health codes. Payers may also want you to append modifier GT (as you would for Medicare).
Eligible providers: The individual states (often the state medical board) determine who may provide telehealth, but generally any provider who may bill an in-office visit may bill for equivalent telehealth services.
Patient location: Some payers strictly limit the locations from which a patient may receive telehealth services, as Medicare does. Other payers are lessening the restrictions to enhance patient convenience and to encourage cost savings.
Provider/Patient interaction: All state parity laws mandate coverage for real-time videoconferencing, similar to that mandated by CMS for Medicare coverage. Fewer states cover “store and forward” technology, or allow exceptions for coverage.
Payment rates: Parity laws may require equal payment for telehealth services. Even where this is not the case, insurers typically pay the same for telehealth as for an equivalent in-person service. In other words, most payers reimburse the standard fee schedule amount for the service billed.
The only surefire way to know whether telehealth services will be covered for a private payer patient, and how you should report those services, is to talk with the payer for verification.
Check Your Facts, Often
As technology and social acceptance advances telehealth practices, further regulations will be necessary. This is a rapidly growing sector so expect new guidelines and coding options often. Just when you think you know it all, it will all change.
Medicare Learning Network, “Rural Health Fact Sheet Series: Telehealth Services,” (Telehealth Services Fact Sheet, May 3, 2017)
For information about parity laws in various states, visit the American Telemedicine Association website
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