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Looking for coding rules for telehealth

  1. Default Looking for coding rules for telehealth
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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!

  2. #2
    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. "

    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.
    Last edited by Mayzoo; 10-30-2018 at 08:08 PM.

  3. #3
    Columbia, MO
    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.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    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)
    "When you have exhausted all possibilities, remember this: You haven't!"
    -Thomas Edison

  5. Default 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!

  6. #6
    Columbia, MO
    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.
    Last edited by mitchellde; 02-08-2019 at 09:49 AM.

    Debra A. Mitchell, MSPH, CPC-H

  7. Default 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

  8. #8
    Columbia, MO
    Medical Billing
    I think you mean modifier GT and you do not use it anymore for Medicare just the POS 02.

    Debra A. Mitchell, MSPH, CPC-H

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