Many patients have utilized telemedicine for medical care during the COVID pandemic and will continue to seek this option going forward. These resources will help refine and improve your delivery of virtual care, and practical implementation tips are offered below.
E/M and Other Medicare Allowed Services
This is a list of eligible CPT/HCPCS codes.
- Use modifier -95 to claim line-item services provided via telehealth.
- Use POS code 10 for telehealth services provided in the patient's home - The location where health services and health related services are provided or received, through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology. (This code is effective January 1, 2022, and available to Medicare April 1, 2022.)
- Use POS 02 for telehealth services provided other than in patient's home - The location where health services and health related services are provided or received, through telecommunication technology. Patient is not located in their home when receiving health services or health related services through telecommunication technology. (Description change effective January 1, 2022, and applicable for Medicare April 1, 2022.)
- Modifier -95 should not be used with virtual check-ins (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.
- During the current PHE, telehealth E/M levels can be based on Medical Decision Making (MDM) OR time (total time associated with the E/M on the day of the encounter). Likewise, CMS has also removed any requirements regarding documentation of history and/or physical exam in the medical record for Telehealth visits.
- -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.”
- -GO: Use of telehealth for purposes of diagnosing stroke.
- 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.
This is a set of telehealth-specific codes for the following use-cases:
- 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.
- Can be any real-time audio (telephone), or "2-way audio interactions that are enhanced with video or other kinds of data transmission."
- 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 virtual check-in 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.
- Should be initiated by the patient since a copay is required. Verbal consent to bill and documentation is required.
- No modifier needed as these are technology based codes.
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.
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.
Online Digital Evaluation and Management (E/M)
Telehealth-specific codes for the following use-cases:
- Given the temporary approval of E/M visits via telehealth, these online codes would primarily be used for patient interactions via a portal.
- Can be done synchronously and asynchronously and audio/video phone can be used (but not a traditional telephone).
- 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.
- 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.)
- Must be patient initiated.
- Cost sharing applies.
- Use only once per 7-day period. 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.
- 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 other 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.
- No modifier needed as these are technology based codes.
|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|
|99423||….21 or more minutes|
Private Payer and State Policies
Many states have issued their own public health emergencies, and some have ended theirs, which results in changes to Medicaid, private payer, and licensure for telehealth.
- The Center for Connected Health Policy (CCHP) is an excellent resource to keep up with state regulations and has two toolkits that track COVID-19 Telehealth Coverage Policies and COVID-19 Related State Actions, which include Medicaid clarification, waivers, and telehealth guidance, prescription and consent waivers, private payer requirements, and cross-state licensing.
- The Alliance for Connected Care also has a chart showing state changes to licensure, coverage, and other changes during COVID-19.
- Full listing of all blanket waivers and flexibilities related to provider enrollment, telehealth, 1135 waivers, and other changes resulting from the COVID-19 public health emergency.
Many Medicare restrictions related to virtual visits have been lifted during the COVID public health emergency. ACP will update this information when the federal PHE ends. Some states have already ended their PHE.
Medicare policies during the emergency:
- Patients can be at home and non-HIPAA compliant communication technology is allowed.
- Practices are allowed to waive cost sharing (copays and deductibles) for all telehealth services All E/M and other services that are currently eligible under the Medicare telehealth reimbursement policies are included in this waiver. This is a list of eligible CPT/HCPCS codes, including which codes are allowed to use audio-only telephone.
- New or established patients.
- Rural and site limitations are removed.
- CMS has issued additional guidance regarding flexibilities specific to FQHCs and RHCs.
- Informed Consent for Telehealth: Although it is not always required, it is important that patients understand the risks and benefits of using telehealth. AHRQ has a simple, customizable consent form and how-to guidance for clinicians on how to explain telehealth. Document verbal consent prior to each telehealth visit until you can receive a signed consent (either digitally or on paper) from the patient.