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COVID-19 Telehealth Coding and Billing Practice Management Tips

Last updated 3/25/2020

In order to mitigate exposure of patients who are sick or at-risk due to other conditions, as well as protect the healthcare workers and community, practices are strongly encouraged to use telehealth whenever possible and to consider establishing protocols and procedures for use by practice staff and clinicians.  Now in a full state of emergency, many Medicare restrictions related to telehealth have been lifted.  Patients can be at home and non-HIPAA compliant technology is allowed. There is no cost sharing for COVID-19 testing. In addition, to encourage use by patients, Medicare is allowing practices to waive cost sharing (copays and deductibles) for all telehealth services.  At this time, CMS does not reimburse for telephone calls (99441-99443).

This toolkit is intended to help practices make adjustments now, and in the coming weeks, due to COVID-19.  This CMS FAQ provides information about cost-sharing requirements for COVID-19 testing and treatment. Any new guidance for physicians will be posted on ACP’s COVID-19 resource page

Consider the following guidelines when billing the below codes:

  • Can be any real-time audio (telephone), or "2-way audio interactions that are enhanced with video or other kinds of data transmission."
  • Established patients only.
  • Any chronic patient who needs to be assessed as to whether an office visit is needed. 
  • Patients being treated for opioid and other substance-use disorders.
  • Nurse or other staff member cannot provide this service. It must be a clinician who can bill E&M services.
  • If an E&M service is provided within the defined time frames, then the telehealth visit is bundled in that E&M service. It would be considered pre- or post-visit time of the associated E&M service and thus not separately billable.
  • No geographic restrictions for patient location. 
  • Should be initiated by the patient since a copay is required. Verbal consent to bill and documentation is required.
  • Communication can use non-HIPAA compliant technology during the COVID-19 public health emergency

Code

Description

Fac Fee

Non-Fac Fee

G2010

Remote evaluation of recorded video and/or images submitted by an established patient (e.g. store and forward), including interpretation with followup with the patient within 24 business hours, not originating from a related E&M service provided within the previous 7 days nor leading to an E&M service or procedure within the next 24 hours or soonest available appointment.

$9.38

$12.27

G2012

Brief communication technology-based service, 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 7 days nor leading to an E&M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.

$13.35

$14.80

Code Description Fac Fee Non-Fac Fee
99421 Patient-initiated digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes 13.35 15.52
99422 ….11-20 minutes 27.43 31.04
99423 ….21 or more minutes 43.67 50.16

Online digital evaluation and management (E/M) services (99421, 99422, 99423) are patient-initiated services with physicians or other qualified health care professionals (QHPs)….requiring evaluation, assessment, and management of the patient. These services are not for the non-evaluative electronic communication of test results, scheduling of appointments, or other communication that does not include E/M. While the patient’s problem may be new to the clinician, the patient must be an established patient. Patients initiate these services through HIPAA-compliant secure platforms, such as electronic health record (EHR) portals, secure email, or other digital applications, which allow digital communication with the clinician. Copays will apply, the patient must be informed and, the information documented in the chart.

Other notes for using 99421-3 codes:

  • Can be done synchronously and asynchronously and audio/video phone can be used (but not a traditional telephone)
  • Must be patient initiated.  The patient can initiate a virtual check-in, the practice can let the patient know about their options. If the patient calls back within 7 days, then the time from the virtual check-in can be added to the digital E/M code and only the digital E/M code is billed. Cost sharing applies to the E/M service; copays are waived for COVID-19 testing, but deductibles still apply.
  • Use only once per 7-day period
  • Clinical staff time is not calculated as part of cumulative time
  • Service time must be more than 5 minutes
  • Do not count time otherwise reported with other services
  • Do not report on a day when the physician or other qualified health care professional reports E/M services
  • Do not report when billing remote monitoring, CCM, TCM, care plan oversight, and codes for supervision of patient in home, domiciliary or rest home etc. for the same communication[s])
  • Do not report for home and outpatient INR monitoring when reporting 93792, 93793)
  • If the patient presents a new, unrelated problem during the 7-day period of an online digital E/M service, then the time is added to the cumulative service time for that 7-day period.

If the patient initiates a call to the physician office this would qualify for the remote check-in code (G2012), the time for the remote (virtual) check-in can be counted toward 99421-3 only if and when the patient calls back, so it is important to document the time. (See CPT book for further details regarding when the 7 days begins, how to count time, which “qualified non-physician health professionals” it applies to, and other documentation requirements.

Code Description Fac Fee Non-Fac Fee
G2061 Qualified non-physician professional online assessment (such as using the patient portal), for up to 7 days, 5-10 minutes cumulative time during the 7 days 12.27 12.27
G2062 ….11-20 minutes 21.65 21.65
G2063 ….21 or more minutes 33.56 33.92

There no new rules specific to the COVID-19 public health emergency.

No change for COVID-19.

  • Established patients only.
  • Involves "asynchronous transmission of healthcare information" from the patient. If the images are not sufficient to perform the evaluation, then do not bill for the service.
  • If an E&M service is provided within the defined time frames, then the telehealth visit is bundled in that E&M service. It would be considered pre- or post-visit time of the associated E&M service and thus not separately billable.
  • Followup can be by phone, audio/video, secure text messaging, email or patient portal communication.
  • Should be initiated by the patient since a copay is required. Verbal consent to bill and documentation is required.
  • Communication must be HIPAA compliant.
  • This is distinct from CCM code 99490, which can be provided without the patient's presence and use any means of communication.
Code Description Fac Fee Non-Fac Fee
99453 Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment 18.77 18.77
99454 Remote monitoring of physiologic parameter(s) (eg, weight, BP, pulse oximetry, respiratory flow rate) initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days 62.44 62.44
99457 Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff, physician, or other qualified health professional time in a calendar month requiring interactive communication with the patient/caregiver during the month 32.84 51.61

For the online assessment codes, it is expected that these services would be patient initiated, but practices may educate their patients about the availability of the service. For more detailed information about how to use these codes, see ACP’s Telehealth Toolkit.

The modifier 95 is used when synchronous telemedicine service rendered via a real-time interactive. Use POS=2 to report the location when health services are provided or received through telecommunication technology.  

-95: ​Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system. Append this modifier to an appropriate CPT code for a real time interaction between a physician or other qualified healthcare professional and a patient who is located at a distant site from the reporting provider. The totality of the communication of information exchanged between the reporting provider and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction.

  • Modifier -95 should not be used with virtual visits (G2012) or the digital evaluations (99421-99423). It is for use with all other telehealth codes that use synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system.

-GQ : Clinicians participating in the federal telemedicine demonstration programs in Alaska or Hawaii must submit the appropriate CPT or HCPCS code for the professional service along with the modifier GQ, “via asynchronous telecommunications system.”

Note:  Medicare stopped the use of modifier -GT in 2017 when the place of service code 02 (telehealth) was introduced.  However, private payer may still be using the modifier -GT.

Telephone only (no video) are reimbursable during this public health emergency by some payers, and in California, all payers at the same rates and cost sharing as in-person services. No modifier is needed for these codes because they are not telehealth – they are audio only telephone. 

Code Description Fac Fee Non-Fac Fee
99441 Telephone E/M service provided by a physician to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hrs or soonest available appointment, 5-10 medical discussion 13.45 14.44
99442 …11-20 minutes 26.71 28.15
99443 …21-30 minutes 39.70 41.14
98966 Telephone assessment and management service provided by a qualified non-physician healthcare professional to an established patient, not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hrs or soonest available appointment, 5-10 min medical discussion      
98967 …11-20 minutes      
98968 …21-30 minutes      

 

Because some service cost sharing will be waived for COVID-19 testing and treatment, it is important to use the appropriate ICD10CM codes:

  • J12.89 (other viral pneumonia)
  • J20.8 (acute bronchitis due to other specified organisms)
  • J80 (acute respiratory distress syndrome)
  • J98.8 (other specified respiratory disorders)

To define the specified virus with the above diagnoses, use B97.29 (other corona virus as the cause of diseases classified elsewhere)

  • Z03.818 (encounter for observation for suspected exposure to other biological agents ruled out)
  • Z20.828 (contact with and suspected exposure to other viral communicable diseases

To define the specified virus with the above diagnoses, use:

  • B97.29 (Through March 30) Other corona virus as the cause of diseases classified elsewhere
  • U07.1 2019-nCoV acute respiratory disease.  Effective April 1, 2020, the CDC has issued a new ICD10CM emergency code.  
  • Z03.818 Encounter for observation for suspected exposure to other biological agents ruled out (possible exposure)
  • Z20.828 Contact with and suspected exposure to other viral communicable diseases (actual exposure)

Use appropriate codes for the signs and symptoms, e.g., R05 (cough), R06.02 (shortness of breath), or R50.9 (fever, unspecified)

NOTE: Do NOT use B34.2 (coronavirus infection, unspecified) because COVID-19 would not be unspecified.

During the COVID-19 public health emergency, rural and site limitations are removed. Telehealth services can now be provided regardless of where the enrollee is located geographically and type of site, which allows the home to be an eligible originating site. However, locations that are newly eligible will not receive a facility fee.

Effective immediately (as of March 17, 2020), the Office for Civil Rights (OCR), the department responsible for enforcing the Health Insurance Portability and Accountable Act of 1996 (HIPAA) regulations, announced they will exercise enforcement discretion for telehealth remote communications during the COVID-19 nationwide public health emergency. During the COVID-19 emergency, physicians subject to HIPAA Rules may communicate with patients, and provide telehealth services, through remote communications technologies that may not fully comply with the requirements of the HIPAA Rule, regardless of whether the service is related to the diagnosis and treatment of conditions related to COVID-19. OCR will not impose penalties for noncompliance with the HIPAA Rules in connection with the good faith provision of telehealth during the COVID-19 emergency.

PLEASE NOTE: This federal enforcement discretion will likely not impact individual states’ laws and regulations regarding protection and security of health information. Separate state action will be required in certain areas – physicians should assess their state-specific privacy laws prior to moving forward.

Physicians may use any non-public facing remote communication product available to communicate with patients (even if this product is not fully compliant with HIPAA Rules) – examples include:

  • Apple FaceTime
  • Facebook Messenger video chat
  • Google Hangouts video
  • Skype

Examples of public-facing products and applications that should NOT be used include:

  • Facebook Live
  • Twitch
  • TikTok

Physicians are encouraged to notify patients that these third-party applications potentially introduce privacy risks, and physicians should enable all available encryption and privacy modes when using such applications​

Physicians seeking additional privacy protections should provide telehealth remote communication services through vendors who are HIPAA-compliant and will enter into a HIPAA Business Associate Agreement (BAA) in connection with the use of their product. The below list of vendors have indicated they provide HIPAA-compliant platforms (NOTE: OCR has not reviewed these vendors BAAs and is not endorsing the use of or suggesting certification for any of the below products):

  • Skype for Business
  • Updox
  • VSee
  • Zoom for Healthcare
  • Doxy.me
  • Google G Suite Hangouts Meet

Additional information from OCR can be found here, including further flexibilities available, as well as obligations that remain in effect under HIPAA as physicians respond to crises or emergencies.

All services that are currently eligible under the Medicare telehealth reimbursement policies are included in this waiver. These are list of eligible codes. See the “Modifiers” tab for more information about how to correctly bill for these CPT services.

The AMA has published guidance in CPT Assistant stating to use 87635. All healthcare entities must manually load it into their EHRs. An excerpt from CPT Assistant is as follows:

This code is effective immediately for use in reporting this testing service. Note that code 87635 is not in the CPT 2020 publication; however, it will be included in the CPT 2021 code set in the Microbiology subsection of the Pathology and Laboratory section.

87635 - ​Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique.

99000 - ​Handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory. (Use if the specimen is prepared by your office and sent to an outside lab, report the specimen collection code.)

99001 - Handling and/or conveyance of specimen for transfer from the patient in other than an office to a laboratory (distance may be indicated) (Use when directing patient to a testing site.)

The Centers for Medicare & Medicaid Services (CMS) developed two new lab testing codes:

U0001​ - Use to report coronavirus testing using the CD) 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test Panel.

U0002 - ​​Use to report validated non-CDC laboratory tests for SARS-CoV-2/2019-nCoV (COVID-19).

If your office is not running the test for COVID-19 or incurring the cost, you will not report these codes.

The AMA has issued some coding guidance that includes how to code different scenarios. The scenarios include examples specifically related to COVID-19 testing. For example, coding for when a patient comes to the office for E/M visit, and is tested for COVID-19 during the visit; receives a telehealth visit re COVID-19 and is directed to come to physician office or physician’s group practice site for testing; receives a virtual check-in/online visit re COVID-19 (not related to E/M visit), and is directed to come to physician office for testing; and more. 

Payer Policies

CDC is encouraging communities, including 1st responders, healthcare “providers,” and health systems to offer telehealth. The federal government is requesting private payers to cover telehealth for COVID-19 as a way to minimize the spread of the virus in the community and clinical settings.  Please note that changes in payer policies are changing from day to day, so be sure and check the policies of your practice’s most common payers.

This COVID-19 resource from the Center for Connected Health Policy (CCHP) provides an up to date summary of telehealth rules, including state licensure and private payer policies regarding telehealth coverage.

In addition to those payers listed in the above CCHP resource, we provide links to supplemental information as we become aware of them:

  • Summary of Medicare and Medicaid Policy Announcements Related to COVID-19: This document summarizes the various flexibilities, telehealth, waivers, and other changes resulting from the COVID-19 public health emergency. Dated 3/19/2020.
  • America’s Health Insurance Plans (AHIP) has put together a list of COVID-19 related announcements from individual health plans.  
  • UnitedHealthcare will cover testing at approved locations for its private, Medicare, and Medicaid members.  For members in states with declared public health emergencies (eg, FL and WA), members may use non-contracted facilities for Part A and Part B services. They will also waive gatekeeper requirements, and reduce out-of-network cost-sharing to in-network amounts.
  • California – The state of California has directed all health plans to reimburse providers at the same rate, whether a service is provided in-person or through telehealth, including video and telephone, and with the same level of cost-sharing as if provided in-person. They have also created a special enrollment period for Californians who wish to enroll in the California Health Benefits Exchange, Covered California.
  • Anthem will pay for telephone calls as well as other telehealth for the next 90 days. Cost sharing varies. Office visit codes (99201-99215) done via telehealth (video+audio connectivity) should be billed with POS=02 and use modifier -95 or –GT. Telephone calls (99441-3 and 98966-8) do not need modifiers because they are audio-only telephone.

Practice Issues

Clinician and Staff Availability

Practices may need to review emergency plans related to telework and employee and clinician absence. 

  • Clinicians who are paid based on production will experience a loss of income. Practices and employers should consider temporary adjustments to compensation formulas to accommodate. 
  • For clinicians who are quarantined, or their patients, consider using telehealth when possible. 
  • Practices may need to consider putting protocols in place for practice staff and clinicians that ensures a number of staff to access the office for those patients who do need to be seen in person and allows access to EHR functionality for processes such as adding patients to the portal and other necessary duties. 
  • Consider using one site or area of your practice for COVID-19 active or suspected patients and assigning specific staff to those areas. Consider using lower-risk staff and clinicians to provide in-person services to these patients. 
  • If necessary, work with your EHR vendor regarding remote access rights for employees who need to work from home. 
  • The CDC offers guidance regarding personnel with exposure to patients with COVID-19. Practices should establish contact with state or local health departments about responsibilities of the practice vs the public health departments. 

Supplies and Testing 

ACP’s clinical guidance includes up-to-date information and resources on testing and treatment protocols, resources specific to PPEs, and much more. Like this toolkit, it is being updated regularly as new information is available. 

  • Access to testing is changing rapidly and varies by locality. Check with your local health department, hospital, reference labs, or state health authorities regarding access to testing. 
  • Distilleries are making hand sanitizers – consider contacting nearby distilleries. 
  • Get as creative as you can with disinfecting supplies. There are some things you can make or use if you need to, such as a dilute bleach solution. Construction companies have N95 masks, check with them. 
  • Check with your health systems and IPAs, who are working to locate supplies. 
  • Ask your patients (such as through your web site or emails) if they have face masks or other PPEs they can donate. 
  • Many people all over the country are sewing masks. 
  • As much as possible, limit the number of staff and clinicians seeing high-risk patients. For moderate to high risk patients, staff wears full PPE in a specified area. By limiting the number of people who come in contact with non-low-risk patients helps conserve PPE. 
  • Although many of these are clinical protocols and are from the hospital, this collection of policies and procedures from the University of Washington offer some practical guidance that practices can use, especially related to triaging patients and conservation of PPEs.