Article

Billing telemedicine in the era of COVID-19

With telemedicine newly important, this guide helps answer questions about security, coding, documentation and more.

The COVID-19 crisis has brought a lot of uncertainty to our doorstep. A big question for the medical community: How will we continue to take care of our patients while trying to practice social distancing? Telemedicine offers a practical method to aid patients while keeping everyone safe.

The purpose of this article is to help guide you through the administrative aspects of telemedicine.

KEY QUESTIONS

Several important concepts are used to define the CPT and HCPCS codes to report telemedicine. Your practice needs to answer the following questions:

  • Who is the patient? Established patient or new patient
  • Who is the provider? Physician, qualified health-care professional (QHP) such as physician assistant or nurse practitioner, or qualified nonphysician (QNP) such as physical therapist, occupational therapist, social worker or dietitian
  • How is communication made? Synchronous (ie, real time audio and video), asynchronous (ie, store and forward image), online (eg, e-mail, patient portal) or telephone without video
  • Who initiated the communication? Patient, physician or physician’s staff
  • What is the objective? Refill medications, schedule appointment, communication of test results, determine whether appointment is needed, physician review of images, query or evaluation and management (E/M).
  • Did the patient consent to be billed? Yes, no or not documented and unknown.
  • What is the context? Did an exam occur within the past 7 days? Does telemedicine result in a service within the next 24 hours or next available appointment?

The answers to these questions are the differentiating parameters that distinguish codes from each other (Table 1).

Table 1. Telemedicine parameters
KEY PARAMETER DEFINITION
EP Established patient Seen within the past 3 years
NP New patient Not seen within the past 3 years1
C Consent by beneficiary Patient gives verbal consent to bill, documented in the chart, and is subject to deductible and co-payment (if any).
PI Patient initiated Episode(s) of patient care initiated by an established patient, parent or guardian
P Physician Medical doctor (MD), osteopath (DO) or optometrist (OD)
QHP Qualified healthcare professional Qualified healthcare professional such as a nurse practitioner or physician assistant
QNP Qualified nonphysician Qualified nonphysician such as physical therapist, occupational therapist, social worker, dietitian
S Secure Health Insurance Portability and Accountability Act (HIPAA)-compliant secure platform such as EHR, secure e-mail or digital application2
SA Stand alone Does not result from a service within the past 7 days or result in a service in the next 24 hours or next available appointment

HIPAA AND SECURITY

It is important to note that HIPAA requirements for secure platforms will not be enforced during this public health emergency, but will be once U.S. Health and Human Services Secretary Azar declares an end to the emergency. So, the parameter that pertains to security is only temporarily relaxed. This relaxed approach applies to technology such as FaceTime and Skype.3

CONSENT AND DOCUMENTATION

Verbal consent is explicitly required in CPT for some telemedicine services; however, it is highly recommended for all of these encounters to avoid acrimony later and preserve a good relationship with the patient. Of course, the extent of the chart documentation will vary, but it is particularly important to note the time devoted to the service. When serial online services occur over a period of a few days, the time is cumulative.

CODING FOR TELEMEDICINE

Two code sets for reporting telemedicine services are available: CPT and HCPCS. The American Medical Association CPT Editorial Panel creates and revises the CPT Manual while the Centers for Medicare & Medicaid Services maintains HCPCS (ie, in this case, the G-codes). There is some overlap between the two code sets. In Table 2, relevant codes for telemedicine are tabulated,4 although not every possible choice, and the differentiating parameters and current Medicare coverage are noted.

Table 2. Codes for telemedicine
CODES5 DEFINITION PARAMETERS COVERED BY MEDICARE
98966 - 98968 Telephone call with qualified non-physician provider (eg, occupational, therapists, social workers) EP, NP, PI, QNP, S Yes
98970 - 98972 and G2061 - G2062 Online digital evaluation and management (E/M) by qualified non-physician providers EP, C, PI, QNP, S, SA Yes
9920x - 9921x Synchronous E/M EP, NP, PI, P, QHP, S Yes
Q3014 Telehealth originating site facility fee S Yes
99421 - 99423 Online digital E/M by physician or qualified healthcare provider (eg, NP, PA)6 EP, C, PI, P, QHP, S, SA Yes
99441 - 99443 Telephone call with physician or qualified healthcare provider EP, NP, PI, P, QHP, S Yes
99446 - 99448 Inter-professional telephone/electronic consultation7 EP, NP, P, QHP, S Yes
G20128,9 Virtual check-in EP, C, PI, P, QHP, S, SA Yes
G20109 Review image; store and forward EP, C, P, QHP, S, SA Yes
920xx (Eye code) General ophthalmological service Cannot be used to report telemedicine10 N/A
Medicare coverage based on instructions in CMS Interim Final Rule (CMS-1744-IFC), which expanded eligibility for reimbursement.

Until very recently, Medicare coverage of telemedicine has been very limited. However, in this COVID-19 public health emergency, Secretary Azar authorized waivers and modifications under Section 1135 of the Social Security Act retroactive to March 1, 202011 that grant CMS more latitude to cover it.12

Within telemedicine, the most thorough interaction is E/M. It entails review of the chart, history, tests (if any), development of a management plan, generate prescription(s), order test(s) and communication with the patient. To be sure, many telemedicine interactions are not E/M but another type of service as detailed in Table 2. Several software applications are available to add real-time video to the phone call, thereby enabling a synchronous telemedicine interaction in a secure manner.

MODIFIERS FOR TELEMEDICINE

Modifiers present another coding challenge and not all payers agree on usage. Within CPT, modifier 95 is used to designate telemedicine for eligible services, those marked with a ★ in the manual.13 Medicare designated modifiers GT (synchronous communication) and GQ (asynchronous communication) under its longstanding regulations,14 but waived the use of them during this COVID-19 crisis. In the March 30, 2020 Interim Final Rule, CMS changed its regulations to require modifier 95 for synchronous communication only and no modifiers for online, telephonic or virtual visits.15

In addition, don’t apply the disaster and catastrophe waiver modifiers DR and CR for telehealth services.

PLACE OF SERVICE

CMS’ place of service code for telehealth is “02,” which signifies “the location where health services and health related services are provided or received, through a telecommunication system.”16 In CMS’ Interim Final Rule published March 30, 2020, they do an about-face. CMS instructs, “report the POS code that would have been reported had the service been furnished in person.”17 That’s not “02”, but “11” (office) unless you are a hospitalist or provide eye care in a hospital or nursing-home setting. This new instruction is retroactive to March 1, 2020. This has a very significant impact on the Medicare payment rate for telemedicine because the non-facility rate is higher than the facility rate that was usually used with POS 02.

SELECTING THE LEVEL OF SERVICE

In 2020, selecting the appropriate level of service for customary E/M services (992xx) is based on history, exam, and medical decision making (MDM), and, under some circumstances involving extensive counseling, based on physician time spent face-to-face with the patient. In CMS’ Interim Final Rule, the agency states, “Beginning January 1, 2021 for office/outpatient E/M visits, the code level will be selected based on either the level of MDM or the total time personally spent by the reporting practitioner on the day of the visit (including face-to-face and non-face-to-face time).”

In a remarkable leap forward, CMS adds, “On an interim basis, we are revising our policy to specify that the office/outpatient E/M level selection for these services when furnished via telehealth can be based on MDM or time, with time defined as all of the time associated with the E/M on the day of the encounter; and to remove any requirements regarding documentation of history and/or physical exam in the medical record. This policy is similar to the policy that will apply to all office/outpatient E/Ms beginning in 2021 under policies finalized in the CY 2020 PFS final rule.”18

For telemedicine services that are defined in CPT as exclusively time based, the level of service is determined by the time spent in medical discussion with the patient directly or indirectly — 5 minutes is the shortest (Table 3). Most are fairly abbreviated. Longer time intervals, beyond 20 or 30 minutes, are unlikely and viewed with skepticism by third-party payers. They are omitted from Table 3 to conserve space.

Table 3. Level of service
CODE DESCRIPTION TIME INTERVAL CY 2020 MPFS
G2012 Virtual check-in 5-10 min $15
G2010 Remote evaluation of image(s) N/A $12
99201 New patient E/M, minimal 10 min $47
99202 New patient E/M, problem focused 20 min $77
99212 Established patient E/M, problem focused 10 min $46
99213 Established patient E/M, expanded problem focused 15 min $76
99421 Online E/M 5-10 min $16
99422 Online E/M 11-20 min $31
99423 Online E/M 21 or more $50
99441 Phone call 5-10 min $14
99442 Phone call 11-20 min $28
99443 Phone call 21 or more $41
99446 Interprofessional telephone/internet consultation 5-10 min $18
99447 Interprofessional telephone/internet consultation 11-20 min $37
99448 Interprofessional telephone/internet consultation 21-30 min $56
Medicare allowed amounts based on instructions in CMS Interim Final Rule (CMS-1744-IFC) to “…report the POS code that would have been reported had the service been furnished in person,” which increased reimbursement, in most cases, to the non-facility rate in the MPFS.

While most telemedicine originates with patients, it may also originate from another physician or provider. Where real-time, synchronous, video and audio, secure connection are used, the originating site is eligible for some reimbursement. In CY 2020, HCPCS code Q3014 (telehealth originating site facility fee) is paid 80% of the lesser of the actual charge or $26.65.19

CONCLUSION

In light of the unprecedented health emergency created by the coronavirus, CMS has taken a number of dramatic steps to utilize telemedicine and telehealth during this crisis.20 Given the serious threat the coronavirus poses to physicians, their staff and patients, it is a welcome method for everyone concerned, enabling treatment of patients remotely without a risky visit to the office. While telemedicine isn’t suitable for emergent conditions, it can help in many instances.

The billing and coding aspects of telemedicine are largely unfamiliar to most ophthalmologists and optometrists. This article summarizes the relevant codes, parameters, time requirements and Medicare coverage. OM

REFERENCES

  1. Medicare Claims Processing Manual, Chapter 12, Section 30.6.7, subsection A. Definition of a new patient. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf Accessed Mar. 25, 2020.
  2. American Academy of Ophthalmology. Academy, Federal Agencies Issue New Telehealth Guidance for COVID-19. https://www.aao.org/eye-on-advocacy-article/academy-federal-agencies-issue-telehealth-guidance Accessed Mat. 20, 2020.
  3. CMS-1744-IFC. p. 49. March 30, 2020 https://www.cms.gov/files/document/covid-final-ifc.pdf Accessed Apr. 5, 2020.
  4. CMS. Medicare Telemedicine Health Care Provider Fact Sheet. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet .
  5. 2020 CPT Professional Edition
  6. Foley & Lardner LLP. Understanding Medicare’s New Remote Evaluation of Pre-recorded patient information (asynchronous telemedicine) https://www.foley.com/en/insights/publications/2018/11/understanding-medicares-new-remote-evaluation-of-p . Accessed Mar 25, 2020.
  7. CMS. Medicare Claims Processing Manual, Chapter 12, 190.3 Telehealth consultations. Codes G0425-G0427 and G0406-G0408 to report inpatient telehealth consultations.
  8. Coding Intel. Virtual communication: two new HCPCS codes G2010 and G2012. https://codingintel.com/virtual-communication-new-hcpcs-codes-g2010-and-g2012 . Accessed Mar. 25, 2020.
  9. Nixon Law Group. How to get reimbursed for virtual check-ins under HCPCS code G2012. https://www.nixonlawgroup.com/nlg-blog/2018/11/5/how-to-get-reimbursed-for-virtual-check-ins-under-hcpcs-g2012 . Accessed Apr. 5, 2020.
  10. 2020 CPT Professional edition. The ★ symbol is used to identify CPT codes that are eligible for telemedicine, and use modifier 95 (synchronous TM).
  11. CMS. Medicare Fee-for-service response to the public health emergency on the coronavirus (COVID-19). https://www.cms.gov/files/document/se20011.pdf . Accessed Mar. 25, 2020.
  12. CMS. Medicare Telemedicine Health Care Provider Fact Sheet. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet Accessed Mar. 19, 2020.
  13. 2020 CPT Professional Edition.
  14. MCPM Chapter 12, §190 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf . Accessed Mar. 25, 2020.
  15. CMS-1744-IFC. p. 49. March 30, 2020 https://www.cms.gov/files/document/covid-final-ifc.pdf Accessed Apr. 5, 2020.
  16. CMS. Place of service code set. https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set Accessed Mar. 27, 2020.
  17. CMS-1744-IFC. p. 15. March 30, 2020 https://www.cms.gov/files/document/covid-final-ifc.pdf Accessed Apr. 5, 2020.
  18. CMS-1744-IFC. p. 136. March 30, 2020 https://www.cms.gov/files/document/covid-final-ifc.pdf Accessed Apr. 5, 2020.
  19. CMS-1715-IFC. https://www.federalregister.gov/documents/2019/11/15/2019-24086/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other Accessed Mar. 25, 2020.
  20. CMS. Medicare Telehealth Frequently Asked Questions. March 17, 2020. https://edit.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf . Accessed Mar. 25, 2020.

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