Wiki Looking for coding rules for telehealth

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Jean Cosgrove

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Based on the large number of posts for Telehealth billing questions and the low (very very low) number of responses, I'm guessing that everyone is looking for a current billing guide including billing codes, CPT codes, HCPCS, modifiers, place of service, etc etc, by payer (Medicare, Medicaid, Commercial). Is there anyone out there that has successfully pulled together such a document/information that they would be willing to share. ? The whole CPC world awaits your answer!
 
Here is an a small amount of information I have accumulated as excerpt of information for the state of TX.

"Sec. 1455.004. COVERAGE FOR TELEMEDICINE MEDICAL SERVICES AND TELEHEALTH SERVICES. (a) A health benefit plan may not exclude from coverage a covered health care service or procedure delivered by a preferred or contracted health professional to a covered patient as a telemedicine medical service or a telehealth service solely because the covered health care service or procedure is not provided through an in-person consultation.

(b) A health benefit plan may require a deductible, a copayment, or coinsurance for a covered health care service or procedure delivered by a preferred or contracted health professional to a covered patient as a telemedicine medical service or a telehealth service. The amount of the deductible, copayment, or coinsurance may not exceed the amount of the deductible, copayment, or coinsurance required for the covered health care service or procedure provided through an in-person consultation.

(c) Notwithstanding Subsection (a), a health benefit plan is not required to provide coverage for a telemedicine medical service or a telehealth service provided by only synchronous or asynchronous audio interaction, including:

(1) an audio-only telephone consultation;

(2) a text-only e-mail message; or

(3) a facsimile transmission. "


https://statutes.capitol.texas.gov/D...tm/IN.1455.htm

When I researched this for my own child a few months ago , I was told by our health insurance (BCBSTX), that telehealth is covered (with a $25.00 copay) if we use one of their telehealth doctors. We could use our own doctor for telehealth, but the fee is $200.00 (99285), $150 (99284) etc......regardless of the fact she has meet her maximum annual out of pocket. Telehealth is an exception to the annual maximum out of pocket limits for our insurance. Her doc's cash telehealth price was $200.00 for the 99285 visit, so I passed on bothering with a claim. BTW, they did state that not all BCBSTX plans covered telehealth.

I am not sure based on my research that there is an "easy" way to make a guide given that the information seems to be state, insurance company AND group driven. It took me 90 min on the phone with my own insurance company to piece the above paragraph of information, and about a week of digging through many sources to find Texas rules on the subject.
Someone may do it someday, but I did not find one a few months ago.
 
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Telehealth is covered by Medicare and in some states is required coverage by all payers. BUT Telehealth has very strict requirements that must be met. One of the most important being that the originating site cannot be the patient home or patient place of employment. There are also geographic requirements that must be met to qualify. I have a fair amount of research in this area and there is a lot if info on line that you can look up.
 
Agree with both previous posters said. Telehealth has been around for a while, and I don't see it going anywhere. Just remember and follow the very stringent rules, and you should be fine.

I did notice that CMS is trying to update the guidelines of what is required to bill telehealth. In their "Patients over Paperwork" directive, they mention:

"The proposals, part of the Physician Fee Schedule (PFS) and the Quality Payment Program (QPP), would also modernize Medicare payment policies to promote access to virtual care, saving Medicare beneficiaries time and money while improving their access to high-quality services no matter where they live. Such changes would establish Medicare payment for when beneficiaries connect with their doctor virtually using telecommunications technology (e.g., audio or video applications) to determine whether they need an in-person visit."..."Extensive public feedback the agency has received has highlighted a need to streamline documentation requirements for physician services known as “evaluation and management” (E&M) visits, as well as a need to support greater access to care using telecommunications technology."

"Provisions in the proposed CY 2019 Physician Fee Schedule would support access to care using telecommunications technology by:

*Paying clinicians for virtual check-ins – brief, non-face-to-face appointments via communications technology;
*Paying clinicians for evaluation of patient-submitted photos; and
*Expanding Medicare-covered telehealth services to include prolonged preventive services."

So telehealth is definitely on CMS' radar. What the end result will be is still unclear.

And to answer the author's request; no I do not have a document, however I think there is plenty of resources out there to put something together:

CMS MLS Telehealth

Another CMS Telehealth article (October)
 
Converting visits to phone due to inclement weather

Hello! The clinic I'm working at is asking for us to bill phone consults as an in-office visit due to inclement weather on a certain day (instead of canceling patient discussions we converted them to phone). I feel like this should still be coded as a telehealth visit and not in office. Does anyone know exactly how we should handle this or where I can find exact info on how this should be coded?

Thank you!
 
Phone calls are not telehealth. Phones calls are billed using the 99441-99444 codes or the 98966-98968 codes. Phones calls must be patient inititated and cannot be a scheduled encounter. telehealth must meet all of the telehealth rules meaning the patient must be located in a qualifying area and must be in a qualifying originating site which is not their home or place of business. You cannot bill a phone call as an office visit or as telehealth as it does not meet the qualifications for either.
 
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Telehealth

Each state has guidelines
To find those, start by looking on your state Medicaid website for info. Guides will list approved providers and according to the scope of practice they can bill their codes with qualifing modifiers
Look up your state laws too, document requirements ect
Medicaid requires POS 2, with modifier QT
Commercial requires POS 2, with modifer 95
 
how do you code telehealth visits, have a provider that did non face to face, but did correspond with the patient via internet. what e&m/modifiers do we use?
 
Again internet visits are not telehealth you need to look at the new codes that replace 99444 for internet communications. These are 99421-99423 and the are listed after the 99441-99443 codes. Read all the information regarding the use of these in the code book.
 
mitchellde said:
Again internet visits are not telehealth you need to look at the new codes that replace 99444 for internet communications. These are 99421-99423 and the are listed after the 99441-99443 codes. Read all the information regarding the use of these in the code book.
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In all the research that's being done and the communication amongst colleagues, some are telling me that these codes you mention (99421-99423) are for portal use only initiated by the patients or evisits, which to me mean communication by email. And of course the carriers aren't helping us much as they say they can't tell us how to code. Help please?

From the AMA:
The new codes are spurred by digital health tools that are growing in popularity, such as patient portals. These tools enable patients and physicians to connect asynchronously and outside of face-to-face settings, making it easier for patients with transportation and scheduling barriers to get questions answered and receive care.
The new CPT codes report online digital evaluation services, or e-visits. The codes describe patient-initiated digital communications provided by physicians or other qualified health professionals—codes 99421, 99422 and 99423. Three others describe similar interactions when they involve a nonphysician health professional—98970, 98971 and 98972.
 
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Yes they are patient initiated. But they are not telehealth. I am not sure what your question is. Telehealth has restrictions as to originating site and distant provider and uses the 02 POS and regular office visit codes
 
mitchellde said:
Yes they are patient initiated. But they are not telehealth. I am not sure what your question is. Telehealth has restrictions as to originating site and distant provider and uses the 02 POS and regular office visit codes
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Hi Debra,

Do you the requirements for when we can use the telephone visit codes? Our clinic providers are asking about using these in light of the COVID-19 outbreak, to assist patients from coming into the clinics.
98966​
Hc pro phone call 5-10 min
98967​
Hc pro phone call 11-20 min
98968​
Hc pro phone call 21-30 min
99441​
Phone e/m phys/qhp 5-10 min
99442​
Phone e/m phys/qhp 11-20 min
99443​
Phone e/m phys/qhp 21-30 min
I do see the language within that states:
These codes are used to report episodes of patient care initiated by an established patient or guardian of an established patient. If the telephone service ends with a decision to see the patient within 24 hours or next available urgent visit appointment, the code is not reported; rather the encounter is considered part of the preservice work of the subsequent E/M service, procedure, and visit. Likewise, if the telephone call refers to an E/M service performed and reported by that individual within the previous seven days (either requested or unsolicited patient follow-up) or within the postoperative period of the previously completed procedure, then the service(s) is considered part of that previous E/M service or procedure.

So is your understanding that we can bill for these services once within a 7 day timeframe, as long as the patient isn't seen in that time as well by that provider for the same service or related to that service? We would only use the 98966-98968 code range for non-physician, who would this include? Any help clarifying this for me would be appreciated.

Thank you,
Diana
 
Does anyone know in order to bill telehealth services 99213-99215 with modifier does there have to be a permanent record of the video/audio saved somewhere?
 
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