prepared by Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, COC
March 19, 2020
The most important thing to remember is that payers have
differing definitions of what they consider telehealth. I recommend checking with the applicable
insurer for the most up-to-date information affecting requirements for coding
and billing of telehealth services. A
few things to ask about:
- What are the effective dates? Most insurers are limiting this exemption to
a specific period of time.
- What services are covered?
- How are those to be billed?
- Do we use telehealth codes or office visit
- What place of service?
- What modifiers are necessary?
- For fee-for-service, traditional Medicare
The information below pertains to the major payers in
Alabama as of 3/18/2020 –
Blue Cross Blue Shield of Alabama is allowing
providers to bill for phone call treatment of existing patients under the
established patient office visit codes from 3/16/2020 – 4/16/2020. They are allowing codes up to 99213 with
place of service code 02 (zero two) for telehealth. No modifier is
required. Many providers are concerned
about reaching that level of service when no examination can be performed. Remember that established patient office
visits require only two of the three key components – history, examination,
medical decision-making. If the
physician documents an expanded problem-focused history and low complexity
medical decision-making, 99213 will be supported. This must be the physician speaking with the
patient, not the office staff.
Alabama Medicaid normally requires separate
credentialing for providers performing telehealth; however, that restriction
has been waived 3/16/2020 – 4/16/2020 (dates of service). Medical providers may bill established-patient
evaluation and management codes 99211, 99212 and 99213 for telephone
consultations. Psychologists and
behavioral health professionals should bill 90832, 90834, 90837, 90846, 90847
and H2011. A dental provider should bill D0140.
Place of service code 02 (zero two) for telehealth and modifier CR are
required. Verbal consent must be
obtained and documented in the medical record.
These visits will count against the patient’s office visit limit of 14
visits per year.
United Health Care is waiving originating site
restrictions for their commercial, Medicare Advantage, and Medicaid plans. The patient may be at home or at another
location. All the other requirements for
telehealth must be met – real-time audio and video communication system
required. These include the place of service 02 and the GQ (asynchronous
telecommunications system) or GT (interactive audio and video telecommunication
system) modifier. This waiver is only in
effect until April 30, 2020.
Fee-For-Service Medicare DOES NOT allow telephone calls to be
billed as telehealth. The PHE waiver
provides three specific exceptions to the existing telehealth regulations:
- the patient can be in their home or other
location – they do not have to be in a healthcare facility in a HPSA.
- the audio-video link can be something as simple
as Skype or FaceTime or Facebook Messenger video calls – but it has to be a
real-time audio AND video one-to-one connection, not something public-facing
- costshare can be waived – it is not
automatically, but it can be waived at the providers’ discretion.
CMS also stated that they will not audit to verify that
there is an established patient relationship.
Services are limited to the list of telehealth services at: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes
This does include office visits, consultations, Transitional Care Management, and Annual Wellness Visits. Place of service is 02 (zero two) for telehealth. No modifier is necessary unless you are billing from a CAH Method II hospital (GT) or you are treating the patient for an acute stroke (G0). There is also a modifier for a telemedicine demonstration project in Alaska or Hawaii (GQ).
NOTE: Although CMS stated that no modifier is necessary, Palmetto GBA is requesting modifier CR be appended for tracking purposes.
For services that have a site of service differential,
payment will be made at the facility rate.
CMS has not specified an end date for these exceptions, just
that they will be allowed as long as the Public Health Emergency declaration is
If there is not a real-time audio-video connection, then you
are limited to one of the following:
- G2012 – Brief communication technology-based
service, e.g. virtual check-in, by a physician or other qualified health care
professional who can report evaluation and management 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
- G2010 – Remote evaluation of recorded video
and/or images 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
7 days nor leading to an E/M service or procedure within the next 24 hours or
soonest available appointment
Please note the following restrictions:
- Established patients only (same definition as
for other E&M services)
- Verbal consent required and must be documented
in the patient’s medical record
- No service-specific documentation requirements
but medical necessity must be documented.
- May only be billed by those providers who can
perform and bill E&M services
To clarify – G2012 has been in effect since 1/1/2019 – it is
supposed to be for an established patient, but CMS has said they will not audit
for that requirement during this time.
It does not require the video link, so it is really the only option for
phone calls. It cannot be related to an
office visit within the past 7 days, as that would be considered part of the
work of the already-billed office visit.
And if the doctor tells the patient to come in at the first available
appointment, it can’t be billed as it would be considered the pre-work for the
upcoming office visit. As it specifies
5-10 minutes of medical discussion, time should be documented.
For email or portal communication, we also have these codes,
new for 2020:
- #99421 – Online digital evaluation and
management service, for an established patient, for up to 7 days, cumulative
time during the 7 days; 5-10 minutes
- #99422 – …11-20 minutes
- #99423 – … 21 or more minutes
Please note the following restrictions:
- Patient-initiated digital communications
requiring a clinical decision that would otherwise be made during an office
- Physician/Qualified Healthcare Professional
(QHP) time only
- Not billable if patient seen in person or through
telehealth within 7 day period
For All Payers –
There have been questions on how to perform a visit by phone
or audio-video without being able to examine the patient. First of all, established patient visits
require two of the three key components:
history, examination, and medical decision-making. A visit can be billed based on history and
medical decision-making. However, some
examination can be done without laying hands on the patient. Observation can be done through video, and
sometimes just through audio. A
physician can observe skin tone, abnormal movements, respiratory effort and
many other exam elements without being able to necessarily touch the
patient. A complete Psychiatric exam can
be accomplished through talking with the patient.
For example, the patient calls in with complaint of dysuria.
The physician documents the complaint (Duration, Timing) and further asks
questions about fever, nausea and vomiting (Constitutional and Gastrointestinal
Review of Systems). He also reviews the
patient’s Past Medical History and Allergies.
Based on her previous history, he suspects that the patient has a
urinary tract infection and orders an antibiotic.
A patient with asthma calls in with an exacerbation – the
physician can actually hear the patient wheezing over the telephone – that
would be documented as a problem-focused examination.
The key point is that the physician himself must have the
conversation with the patient on the phone or through the audio-video link. This may be something that a nurse may have
handled previously, but now it must be performed by the physician to be