Telemedicine Takes Healthcare Into the 21st Century
Update your understanding of how to code telehealth services now and in the future.
Disclaimer: At press time, this information was accurate, and the PHE for COVID-19 pandemic was in full effect. We hope by the time you read this, the PHE has been lifted. Except where noted, the guidance in this article is applicable during normal times.
Without telehealth, the COVID-19 pandemic could be much worse. Imagine if practitioners were not able to socially distance their infected patients from their healthy patients. Think of all the people who would not seek medical attention if it meant leaving their homes. Telehealth has enabled practitioners to save thousands, maybe millions, of lives in the past few months.
The outcome would have been very different if Congress had not stepped in, and the Centers for Medicare & Medicaid Services (CMS) had not exercised its Section 1135 waiver authority. This allowed the agency to lift certain restrictions for telehealth coverage and expand healthcare workers’ outreach to Medicare patients who could not leave their homes for fear of contracting or spreading the coronavirus.
Unfortunately, the rapid-fire changes to the Medicare telehealth policy created a lot of confusion for medical coders and billers. Associations, including AAPC, have been inundated with questions. What is telehealth? What modifier do I use? And hundreds of other questions related to coverage and claims payment.
This article serves as a general overview of what telehealth and telemedicine are and how to code the services for Medicare Part B — before, during, and after the public health emergency (PHE) for the COVID-19 pandemic.
What Are Telehealth and Telemedicine?
The definitions of telehealth and telemedicine may vary depending on who you ask. Generally, telehealth is all-encompassing (including training and administration), and telemedicine is limited to clinical services only. CMS uses the terms telehealth and telemedicine interchangeably (as will we).
For Medicare, a traditional telehealth service uses an interactive audio and video telecommunications system to conduct real-time communication between the patient at the originating site and the provider at the distant site.
Individual telehealth services need to be initiated by the Medicare patient; however, practitioners may educate patients, on their own initiative, about the availability of the service prior to patient initiation. In other words, the patient must consent to the service before or at the same time it takes place. Consent may be obtained by auxiliary staff under general supervision.
What Are Originating and Distant Sites?
As a condition of payment, the patient must be present for and participate in the telehealth visit. The patient must go to the originating site located in either a county outside a metropolitan statistical area, as determined by the U.S. Census Bureau, or a rural Health Professional Shortage Area in a rural census tract, as determined by the Health Resources and Services Administration.
Facilities authorized to serve as originating sites are:
- Physician offices
- Hospitals, critical access hospitals (CAHs)
- Rural health clinics
- Federally qualified health centers
- Hospital-based or CAH-based renal dialysis centers, renal dialysis facilities
- Homes of patients with end-stage renal disease (ESRD) receiving home dialysis
- Skilled nursing facilities
- Mobile stroke units
- Providers participating in a federal telemedicine demonstration project, regardless of location
<During the PHE for COVID-19: The originating site component of the definition for telehealth is waived. “Starting on March 6, 2020, Medicare can pay for telehealth services, including office, hospital, and other visits furnished by physicians and other practitioners to patients located anywhere in the country, including in a patient’s place of residence.” (CMS-1744-IFC p12)>
Distant site practitioners who can furnish and receive payment for covered telehealth services are:
- Nurse practitioners
- Physician assistants
- Nurse midwives*
- Clinical nurse specialists*
- Certified registered nurse anesthetists*
- Clinical psychologists and licensed clinical social workers*
- Registered dietitians and nutrition professionals*
* Within their scope of practice and consistent with Medicare benefit rules.
<During the PHE for COVID-19: CMS expanded this list to include medical residents who are directly supervised by the teaching physician, either in person or via interactive telecommunications technology, during the key portion of the service. On April 30, CMS further expanded the list to include “all practitioners eligible to bill Medicare.”>
What Are Medicare Telehealth Services?
Not all Medicare telehealth services have dedicated codes; many are reported using codes that describe face-to-face services such as evaluation and management (E/M), mental health, and preventive care. There were 44 telehealth codes at the start of 2020, including three newly added HCPCS Level II codes for office-based treatment of opioid use disorder (G2086-G2088).
In the CPT® code book, codes for synchronous telemedicine services are listed in Appendix P and are marked with a star symbol in the Tabular List. Not every CPT® code is payable under Medicare, however.
<During the PHE for COVID-19: The following CPT® codes have been added to the Medicare telehealth code list (effective March 1, 2020):
- Emergency department visits (99281-99285)
- Initial and subsequent observation, and observation discharge day management (99217-99220, 99224-99226, 99234-99236)
- Initial hospital care and hospital discharge day management (99221-99223, 99238-99239)
- Initial nursing facility visits and facility discharge day management (99304-99306, 99315-99316)
- Critical care services (99291-99292)
- Domiciliary, rest home, or custodial care services, new and established patients (99327-99328, 99334-99337)
- Home visits, new and established patients (99341-99345, 99347-99350)
- Inpatient neonatal and pediatric critical care (99468-99469, 99471-99473, 99475-99476)
- Initial and continuing intensive care services (99477-99480)
- Care planning for patients with cognitive impairment (99483)
- Group psychotherapy (90853)
- ESRD services (90952-90953, 90959, 90962)
- Psychological and neuropsychological testing (96130-96133, 96136-96139)
- Therapy services, physical and occupational therapy (97161-97168, 97110, 97112, 97116, 97535, 97750, 97755, 97760-97761, 92521-92524, 92507)
- Radiation treatment management (77427)
CMS updated this list on April 30 to add several services that may be furnished via telehealth and to note which services may be furnished using audio-only communications.>
The most up-to-date code list of CMS-allowed telehealth services is available on the CMS website.
<During the PHE for COVID-19: CMS is also relaxing the requirements for many existing telehealth codes. For example:
- Monthly “hands-on” clinical examinations of the vascular access site, reported with ESRD codes, may be furnished via telehealth.
- Limits to behavioral health codes 96156, 96158, 96159, 96164-96165, 96167, 96168, 96170-96171 are suspended as of March 30, 2020, until further notice.
- Frequency restrictions are removed for subsequent inpatient visit codes 99231-99233, subsequent nursing facility visit codes 99307-99310, and critical care consultation codes G0508-G0509.
- The limitation in many E/M code descriptions that requires patients to be either new or established is waived.
- Office/outpatient E/M level selection furnished via telehealth can be based on medical decision making (MDM) or time. You do not need to consider the history and exam components for the level of service.>
Medicare also pays separately for professional services furnished remotely using communications technology-based services (CTBS). These services, which Medicare does not consider to be telehealth, include virtual check-ins, e-visits, and remote patient monitoring (RPM).
What Are Virtual Check-Ins?
CMS finalized separate payment for virtual check-ins in the 2019 Medicare Physician Fee Schedule (MPFS) final rule. This CTBS service may be reported by physicians and other practitioners who are qualified to furnish E/M services. These services are not limited by setting or location, during the PHE or otherwise.
Report virtual check-ins services to Medicare, as appropriate, with:
G2010 Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment
G2012 Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
Virtual check-ins (G2012) are appropriate for established Medicare patients who require a brief communication service with a practitioner, generally over the phone, to determine if an E/M visit is necessary. Remote evaluation services (G2010) involve the patient sending an image or video for the practitioner to assess.
<During the PHE for COVID-19: Practitioners who are eligible to bill Medicare may furnish these services to both new and established patients. Clinicians may provide RPM services to patients with acute and chronic conditions and for patients with only one disease. Patients do not have to be diagnosed with the coronavirus (ICD-10-CM code U07.1 COVID-19).>
Tip: “As long as all requirements for billing both codes are met, and time and effort are not being counted twice, HCPCS codes G2010 and G2012 may be billed by the same practitioner, for the same patient, on the same day,” according to CMS.
Watch out for unbundling. These codes are not separately payable when related to an E/M visit occurring up to seven days prior or within 24 hours (or the soonest available appointment) after. Note, however, that these codes are separately payable if a different physician or other qualified healthcare professional provides the E/M service. This has not changed during the PHE.
<During the PHE for COVID-19: Clinicians are permitted to use a wider array of social media platforms that allow for video chat such as FaceTime and Skype.>
What Are E-visits?
E-visits may be initiated by an established patient through an online portal managed by the provider. These services are generally used to determine if an E/M visit is necessary. There are no geographic or location restrictions for these visits. Report telehealth e-visits with:
- CPT® time-based online digital E/M service codes 99421-99423 when furnished by a physician or nonphysician practitioner who may bill for E/M services; or
- HCPCS Level II time-based online assessment and management service codes G2061-G2063 when furnished by a non-physician practitioner who may not bill for E/M services.
Billing Medicare Part B
Under the MPFS, there are two payment rates for telehealth services:
- The facility rate (paid to a professional when a service is furnished in a care setting, which reflects the facility’s costs paid to the originating site), separately billed with Q3014 Telehealth originating site facility fee; and
- The non-facility, or office, rate.
Submit traditional telehealth services using place of service (POS) 02 Telehealth. Do not use POS 02 on claims for CBTS such as virtual check-ins and e-visits (report the originating POS).
<During the PHE for COVID-19: Effective March 1, 2020, providers may bill for telehealth visits at the non-facility rate:
- Bill telehealth services using the POS code you would have otherwise used had the provider furnished the service in person.
- Append modifier 95 Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system to professional services furnished via telehealth. Remember: Check the telehealth code list on the CMS website for applicable codes.
- Append modifier CS to encounters related to COVID-19 testing if cost-sharing is being waived.>
Other modifiers that may be appropriate:
- Modifier G0 Telehealth services for diagnosis, evaluation or treatment of symptoms of an acute stroke
- Modifier GT Via interactive audio and video telecommunication systems for telehealth services furnished under Critical Access Hospital (CAH) Method II
- Modifier GQ Via asynchronous telecommunication system for asynchronous, or “store and forward,” transmission of medical information in Alaska and Hawaii federal telemedicine demonstration programs
<During the PHE for COVID-19: Temporary policy changes have been made to expand telehealth services in every healthcare setting. Check the CMS website for updated guidance to the Medicare telehealth policy.>
Hope for the Future
Telehealth is revolutionizing the way providers practice medicine. It enables providers to treat individuals who may not otherwise seek medical attention. Advancements in technology and interoperability will further expand the benefits of telehealth to our nation. And coverage and reimbursement for these services, as they become available, will prepare us for whatever lies ahead.
When we think of telehealth, we associate it with technology. This leads to the assumption that telehealth is a relatively new concept. That’s not quite right. According to an article published by the National Academy of Sciences, there was talk of the telephone being used to reduce unnecessary office visits just three years after it was patented in 1876. The radio was the next technological breakthrough that led forward-thinkers to imagine a device that would allow doctors to examine their patients over a distance using video — a prediction made in 1925! Nearly 100 years later, telehealth is not only possible but essential — the COVID-19 pandemic has proven that to be true. It’s time to take telehealth into the 21st century.
82 FR 53006, Nov. 17, 2017, CY 2018 PFS final rule: https://www.govinfo.gov/content/pkg/FR-2017-11-15/pdf/2017-23953.pdf
Other CMS resources: https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf