In November 2018, CMS finalized the 2019 Physician Fees Schedule, which contains significant changes aimed at modernizing the healthcare system by using technology, reducing administrative burden and improving the doctor-patient relationship.1,2 While CMS’s interpretation and implementation of telehealth is amongst the most restrictive, this latest release somewhat expands and clarifies the rules.
However, on March 6, 2020, President Trump signed into law new emergency legislation that covers a number of provisions, one of which allows Health & Human Services (HHS) to provide guidance on waiving specific rules regarding the provision of telehealth services. On March 17, HHS issued its specific guidelines for these waivers, which are retroactive to March 6, 2020.
Ordinarily, telehealth-delivered services under Medicare are regulated in statute by 1834(m) of the Social Security Act, which limits the use of telehealth to certain services, providers, technology (mainly live video) and patient locations (certain types of healthcare facilities in rural areas). The CMS rule expresses concern that these requirements may be limiting the coding for new kinds of services that use specific communication technology.
Now, using a 1135 waiver, CMS relaxed the rules surround how and where a provider can provide telehealth services:3
- Medicare can pay for office, hospital and other visits furnished via telehealth across the country, including the patient’s place of residence starting March 6, 2020. This allows clinicians the opportunity to provide telehealth services without the location-based restrictions.
- The Office of Inspector General is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.
- The requirement to store communication and ensure HIPAA compliance for all patient communications is not being enforced during this emergency, allowing for telehealth services to be provided using “everyday communications technologies” such as FaceTime or Skype.
Based on these changes, here’s how you document various telehealth services:
- HCPCS code G2012: Brief communication (e.g., virtual check-in) by a physician or other qualified health care professional who can report E/M services, provided to an established patient, not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; five to 10 minutes of medical discussion. Typical reimbursement is approximately $15.
- HCPCS code G2010: Remote evaluation of recorded video, images or both 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 seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment. Typical reimbursement is approximately $12.
- Online digital evaluations: E/M service, for an established patient, for up to seven days, with various cumulative times:
- CPT 99421 - cumulative time of five to 10 minutes. National average reimbursement is $15.52.
- CPT 99422 - cumulative time of 11 to 20 minutes. National average reimbursement is $31.04.
- CPT99423 - cumulative time of 21 minutes or more. National average reimbursement is $50.16.
- Note – These services must be initiated by the patient and generally Medicare coinsurance and deductible apply, although they can be waived during this crisis.
- CPT codes 99452, 99451, 99446, 99447, 99448 and 99449: These cover interprofessional consultations performed via communications technology such as telephone or internet. This supports a team-based approach to care that is often facilitated by electronic medical record technology.
- CPT codes 99201 – 99215: These E/M codes have always been approved for telehealth. Meeting their coding requirement is no different when provided in the office or via telehealth. The 920XX codes, either intermediate or comprehensive are not allowed to be provided via telehealth.
When you are submitting claims, keep these tips in mind: (1) The place of service code should be 02-Telehealth vs. 11-Office when submitting telehealth claims. (2) The use of a modifier on the service code is required. Although there is language that says to use the -GT modifier for Medicare, I advise that modifier -95 is the most appropriate, because it has a definition of “synchronous telemedicine service rendered via a real-time interactive audio and video telecommunication system.”
Clinicians must understand that CMS restricts the use of the virtual check-in and the pre-recorded patient information codes, which can only be used by practitioners who furnish E/M codes.
Pay attention to the rules of each of your contracted medical carriers, as they can differ based on whether the carrier is commercial, Medicaid, Medicare Part C (Medicare Advantage) or traditional Medicare Part B. As always, make sure you are aware of these rules prior to providing the care—never assume that meeting the requirements of telehealth for one carrier means you meet the rules for other carriers. This crisis has changed many things for all of us.
Embracing telehealth services allows you to provide a continuum of care for your patients in a time where they need it the most.
Send your coding questions to firstname.lastname@example.org.
1. Centers for Medicare & Medicaid Services. Final policy, payment, and quality provisions changes to the Medicare physician fee schedule for calendar year 2019. www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year. November 1, 2018. Accessed January 9, 2019.
2. Dizon R. Big changes in 2019 for Medicare telehealth policy. National Telehealth Policy Resource Center Blog. www.telehealthresourcecenter.org/big-changes-in-2019-for-medicare-telehealth-policy. November 6, 2018. Accessed January 9, 2019.
3. Centers for Medicare & Medicaid Services. Medicare telemedicine health care provider fact sheet. www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet. Accessed March 20, 2020.