Health Information Compliance Alert

Published on Thu Mar 16, 2017 PDF

New guidance defines the role of modifier 95.

With its push toward providing value-based care under MACRA, it’s no surprise that CMS has offered guidance and new options to promote advancements in telehealth.

Backtrack: CMS invested in telehealth with new code options in its 2017 Medicare Physician Fee Schedule (MPFS) Final Rule, which moved the practice of telemedicine beyond the traditional venues to more alternative settings for enhanced patient care. The highlights include new CPT^® codes for end-stage renal disease (ESRD)-related services for dialysis (90967-90970); advanced care planning (99497-99498); and critical care consultations (G0508-G0509). The new options went live on Jan. 1, 2017.

Choices: In the 2017 AMA CPT^® manual, Appendix P lists the 79 codes you can use to report synchronous (real-time) telemedicine services. Also new for 2017, CPT^® identifies the appropriate telemedicine codes with a star (★) symbol next to the code in the code set.

POS update: CMS also created a new place of service (POS) code for telemedicine: POS 02 (Telehealth: The location where health services and health related services are provided or received, through a telecommunication system), according to a MLN Matters article released on Aug. 12, 2016. Read the article here: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9726.pdf.

New choices: This year, CPT^® has given you modifier 95 (Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system) to report telemedicine services your physician provides via real-time, interactive audiovisual telecommunications.

Don’t forget to append either modifier GT (Via interactive audio and video telecommunication systems) or GQ (Via asynchronous telecommunications system) to your CPT^® or HCPCS code when you list POS 02 for telemedicine on your claim — if you don’t, expect a denial from your MAC.

Why modifiers? “It’s important for the payers to know if the patient was physically in the office or seen via telemedicine,” says Suzan Hauptman, CPC, CEMC, CEDC, senior principal of ACE Med group in Pittsburgh, Pa. “Because the codes are the same regardless of physical location, the 95 modifier tells this part of the story.”

As for knowing which modifier to choose for real-time services, “practices should check with their respective payers on telemedicine coverage policies and the use of the appropriate modifier — 95 or GT,” says Mary I Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting, Inc.

Reminder: Telemedicine services must meet a certain set of rules to be covered for Part B beneficiaries and questions should be directed to your carrier for clarification. For a list of the current approved telemedicine services approved by Medicare, visit https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.html.