cpt for video visit

2024 Telehealth CPT Codes: Cheat Sheet

Charika Wilcox-Lee, VP, Revenue Cycle Management

Keeping track of telehealth reimbursements accurately directly impacts your healthcare organization’s bottom line. We’ve compiled a list of telehealth CPT codes to help you better navigate telehealth billing for your care program.

Source: American Academy of Sleep Medicine (AASM)

CMS Telehealth & RPM Billing Guidelines [PDF]

In recent years, the Centers for Medicare & Medicaid Services (CMS) have released the physician fee schedule with expanded reimbursement for remote patient monitoring (RPM). The guidelines notably increase reimbursement for other services like remote therapeutic care and chronic care management, while making slight adjustments to allowances for RPM.

Top 4 Common Telehealth Billing Mistakes—And How to Avoid Them

The surge of telehealth adoption in recent years has led to regulatory changes and telemedicine coverage expansion that greatly benefits healthcare providers—if reimbursement is done correctly. Here are the top four common mistakes when billing for telehealth, and how you can avoid them.

Mistake #1: Not keeping up with the correct billing codes

As Medicare regulations change in response to public healthcare needs, the billing codes that you’re already familiar with could change as well. Submitting claims with the wrong code could result in delayed reimbursement and in some worst cases, be flagged for abuse.

Avoid by : Staying up to date with additions or deletions to the list of Medicare telehealth services .

Mistake #2: Not maintaining post-visit documentation

Ensuring that you document the right information during telehealth visits is key to getting prompt payment. For a start, touch base with your administrative team to understand the type of information you should be keeping a record of.

Avoid by : Creating a checklist that you can go over before the telehealth visit for cross-checking purposes.

Mistake #3: Not training your team on telehealth billing processes

Your team already has to keep track of thousands of CPT codes on a daily basis. With the new batch of telehealth CPT codes added to the mix, things can easily get very complicated for your team.

Avoid by : Training your team on the types of codes, processes, and all things reimbursement.

Mistake #4: Not checking with the patient’s insurance beforehand

While most major private payers provide coverage for telemedicine, it’s prudent to call up the payer and confirm if the services offered are covered. The good news is, that you’ll only need to verify this once for that particular policy.

Avoid by : Being more diligent about checking insurance coverage before the patient’s first telehealth visit. Use an insurance verification form to log the call and make sure you’re asking the right questions.

8 Key Updates to Telehealth Reimbursement in 2024

CMS has   released its final rule   for Medicare payments under the Physician Fee Schedule (PFS), introducing significant changes that will impact healthcare providers across the country. To help you stay informed and prepared, we've compiled the eight key updates you need to know.

Telehealth Reimbursement Resources & Expert Support

At Health Recovery Solutions, we provide a host of resources on reimbursement and telehealth billing modeled after best practices that we established from working with our healthcare partners—and we’re ready to help. Whether you're in the early stages of researching the benefits of telehealth and remote patient monitoring for your patients or you have an existing program in place and you're considering options to maximize the value of RPM, our team of experts is here to support you. 

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Telemedicine Codes

Telemedicine and telehealth are used interchangeably throughout the United States healthcare system, in reference to the exchange of medical information from one site to another through electronic communication. Reporting of telemedicine/telehealth services varies by payer and state regulations.

AASM Telemedicine/Telehealth Resources

• AASM Coding FAQs
• AASM Telemedicine Video Library

CMS Telemedicine/Telehealth Codes

The codes below are commonly reported for Medicare patients:

CMS finalized the creation of two additional G codes that can be billed by practitioners who cannot independently bill for E/M services. G2250 and G2251 are billable by certain non-physician practitioners, consistent with the scope of these practitioners’ benefit categories.

CPT Telemedicine Codes

Modifier 95 indicates a synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system. The 2020 CPT® manual includes Appendix P, which lists a summary of CPT codes that may be used for reporting synchronous (real-time) telemedicine services when appended by modifier 95. Procedures on this list involve electronic communication using interactive telecommunications equipment that includes, at a minimum, audio and video.

HCPCS LEVEL II CODES

There are also HCPCS Level II codes that describe telemedicine services.

Place of Service (POS) Code for Telemedicine

On January 1, 2017 the Center for Medicare and Medicaid Services (CMS) introduced place of service (POS) code 02 to identify telemedicine services. The descriptor for POS code 02 is “The location where health services and health related services are provided or received, through telecommunication technology.” Use of the telehealth POS code certifies that the service meets all of the telehealth requirements. Many private payers have also begun requiring use of POS code 02 for telemedicine services.

GT/GQ Modifiers

Medicare previously required providers to submit claims for telehealth services using the appropriate procedure code along with the telehealth GT modifier (“via interactive audio and video telecommunications systems”) or GQ modifier (“via an asynchronous (delayed communications) telecommunications system”). As of January 1, 2018, the GT modifier is only allowed on institutional claims billed under Critical Access Hospital (CAH) Method II since institutional claims do not use a POS code. If the GT modifier is billed by other provider types, the claim line will be rejected. The GQ modifier is still required when applicable (e.g., for those providers participating in the Alaska or Hawaii federal telemedicine demonstration programs).

Additional CMS Telemedicine/Telehealth Resources

• Complete list of CMS Telehealth Services
• General Provider Telehealth and Telemedicine Toolkit
• Medicare Telehealth Frequently Asked Questions (FAQs)
• Medicare Telehealth Services

Note: CPT Copyright 2021 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

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Fact Sheets MEDICARE TELEMEDICINE HEALTH CARE PROVIDER FACT SHEET

Medicare coverage and payment of virtual services

INTRODUCTION:

Under President Trump’s leadership, the Centers for Medicare & Medicaid Services (CMS) has broadened access to Medicare telehealth services so that beneficiaries can receive a wider range of services from their doctors without having to travel to a healthcare facility. These policy changes build on the regulatory flexibilities granted under the President’s emergency declaration. CMS is expanding this benefit on a temporary and emergency basis under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act. The benefits are part of the broader effort by CMS and the White House Task Force to ensure that all Americans – particularly those at high-risk of complications from the virus that causes the disease COVID-19  – are aware of easy-to-use, accessible benefits that can help keep them healthy while helping to contain the community spread of this virus.   

Telehealth, telemedicine, and related terms generally refer to the exchange of medical information from one site to another through electronic communication to improve a patient’s health. Innovative uses of this kind of technology in the provision of healthcare is increasing.  And with the emergence of the virus causing the disease COVID-19, there is an urgency to expand the use of technology to help people who need routine care, and keep vulnerable beneficiaries and beneficiaries with mild symptoms in their homes while maintaining access to the care they need. Limiting community spread of the virus, as well as limiting the exposure to other patients and staff members will slow viral spread.

EXPANSION OF TELEHEALTH WITH 1135 WAIVER: Under this new waiver, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence starting March 6, 2020.  A range of providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, will be able to offer telehealth to their patients.  Additionally, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.

Prior to this waiver Medicare could only pay for telehealth on a limited basis:  when the person receiving the service is in a designated rural area and when they leave their home and go to a clinic, hospital, or certain other types of medical facilities for the service. 

Even before the availability of this waiver authority, CMS made several related changes to improve access to virtual care.  In 2019, Medicare started making payment for brief communications or Virtual Check-Ins , which are short patient-initiated communications with a healthcare practitioner. Medicare Part B separately pays clinicians for E-visits , which are non-face-to-face patient-initiated communications through an online patient portal.

Medicare beneficiaries will be able to receive a specific set of services through telehealth including evaluation and management visits (common office visits), mental health counseling and preventive health screenings. This will help ensure Medicare beneficiaries, who are at a higher risk for COVID-19, are able to visit with their doctor from their home, without having to go to a doctor’s office or hospital which puts themselves and others at risk.

TYPES OF VIRTUAL SERVICES:

There are three main types of virtual services physicians and other professionals can provide to Medicare beneficiaries summarized in this fact sheet:  Medicare telehealth visits, virtual check-ins and e-visits.

MEDICARE TELEHEALTH VISITS :  Currently, Medicare patients may use telecommunication technology for office, hospital visits and other services that generally occur in-person. 

• The provider must use an interactive audio and video telecommunications system that permits real-time communication between the distant site and the patient at home.  Distant site practitioners who can furnish and get payment for covered telehealth services (subject to state law) can include physicians, nurse practitioners, physician assistants, nurse midwives, certified nurse anesthetists, clinical psychologists, clinical social workers, registered dietitians, and nutrition professionals. 
• It is imperative during this public health emergency that patients avoid travel, when possible, to physicians’ offices, clinics, hospitals, or other health care facilities where they could risk their own or others’ exposure to further illness.  Accordingly, the Department of Health and Human Services (HHS) is announcing a policy of enforcement discretion for Medicare telehealth services furnished pursuant to the waiver under section 1135(b)(8) of the Act.  To the extent the waiver (section 1135(g)(3)) requires that the patient have a prior established relationship with a particular practitioner, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency.

KEY TAKEAWAYS:

• Effective for services starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for Medicare telehealth services furnished to patients in broader circumstances.
• These visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits.
• Starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for professional services furnished to beneficiaries in all areas of the country in all settings.
• While they must generally travel to or be located in certain types of originating sites such as a physician’s office, skilled nursing facility or hospital for the visit, effective for services starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for Medicare telehealth services furnished to beneficiaries in any healthcare facility and in their home.
• The Medicare coinsurance and deductible would generally apply to these services. However, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.
• To the extent the 1135 waiver requires an established relationship, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency.

VIRTUAL CHECK-INS: In all areas (not just rural), established Medicare patients in their home may have a brief communication service with practitioners via a number of communication technology modalities including synchronous discussion over a telephone or exchange of information through video or image. We expect that these virtual services will be initiated by the patient; however, practitioners may need to educate beneficiaries on the availability of the service prior to patient initiation. 

Medicare pays for these “virtual check-ins” (or Brief communication technology-based service) for patients to communicate with their doctors and avoid unnecessary trips to the doctor’s office. These virtual check-ins are for patients with an established (or existing) relationship with a physician or certain practitioners where the communication is not related to a medical visit within the previous 7 days and does not lead to a medical visit within the next 24 hours (or soonest appointment available). The patient must verbally consent to receive virtual check-in services. The Medicare coinsurance and deductible would generally apply to these services.

Doctors and certain practitioners may bill for these virtual check in services furnished through several communication technology modalities, such as telephone (HCPCS code G2012). The practitioner may respond to the patient’s concern by telephone, audio/video, secure text messaging, email, or use of a patient portal.  Standard Part B cost sharing applies to both. In addition, separate from these virtual check-in services, captured video or images can be sent to a physician (HCPCS code G2010).

• Virtual check-in services can only be reported when the billing practice has an established relationship with the patient. 
• This is not limited to only rural settings or certain locations.
• Individual services need to be agreed to by the patient; however, practitioners may educate beneficiaries on the availability of the service prior to patient agreement. 
• HCPCS code 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.
• HCPCS code 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.
• Virtual check-ins can be conducted with a broader range of communication methods, unlike Medicare telehealth visits, which require audio and visual capabilities for real-time communication.

E-VISITS:  In all types of locations including the patient’s home, and in all areas (not just rural), established Medicare patients may have non-face-to-face patient-initiated communications with their doctors without going to the doctor’s office by using online patient portals. These services can only be reported when the billing practice has an established relationship with the patient. For these E-Visits , the patient must generate the initial inquiry and communications can occur over a 7-day period. The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G2063, as applicable. The patient must verbally consent to receive virtual check-in services. The Medicare coinsurance and deductible would apply to these services.

Medicare Part B also pays for E-visits or patient-initiated online evaluation and management conducted via a patient portal. Practitioners who may independently bill Medicare for evaluation and management visits (for instance, physicians and nurse practitioners) can bill the following codes:

• 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: Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 11– 20 minutes
• 99423: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes.

Clinicians who may not independently bill for evaluation and management visits (for example – physical therapists, occupational therapists, speech language pathologists, clinical psychologists) can also provide these e-visits and bill the following codes:

• G2061: Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to seven days, cumulative time during the 7 days; 5–10 minutes
•  G2062: Qualified non-physician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11–20 minutes
• G2063: Qualified non-physician qualified healthcare professional assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes.
• These services can only be reported when the billing practice has an established relationship with the patient. 
• This is not limited to only rural settings. There are no geographic or location restrictions for these visits.
• Patients communicate with their doctors without going to the doctor’s office by using online patient portals.
• Individual services need to be initiated by the patient; however, practitioners may educate beneficiaries on the availability of the service prior to patient initiation. 
• The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G206, as applicable.
• The Medicare coinsurance and deductible would generally apply to these services.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA):   Effective immediately, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency.  For more information: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/index.html

Summary of Medicare Telemedicine Services

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Video Visits Billing, Coding and Regulations Information

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 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.

Virtual Check-In

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.

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.

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.

Other Resources

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.   

Coding Q&A: Coding telehealth services and virtual visits

by Stephanie Dybul, MBA, RT, FSIR

July 12, 2020

What are the CPT codes for a virtual video telehealth visit?

A virtual video visit is reported with the same CPT codes that you would use for in-person visits ( 99201 – 99205   new patient visit ;  99211 – 99215   established patient visit ; or  99241 – 99245   consultation visit  [not recognized by CMS, see G-codes]). The service should be reported with a - 95  modifier (confirm your local payer rules). There must be a synchronous two-way audio and visual component to the visit in order to report using these standard codes. Additionally, it should be noted that the place of service (POS) listed on the claim should match wherever the intended POS would have been in normal circumstances. For example, if you typically perform your clinic visit in an on-campus, OP hospital setting, report  POS 22  for  facility  or  POS 11  for  nonfacility/office setting . Currently, telehealth services are reimbursed under the CMS Physician Fee Schedule at the same amount as in-person services.

Are there any special documentation requirements for virtual video visit?

You should document all of the same elements that you would normally, with consideration of what is possible for you to achieve via the video connection. Typical elements of past medical history can be taken, limited examinations can be performed and documentation of your medical decision making (MDM) or time spent counseling should be clearly stated. However, CMS is removing requirements regarding documentation of history and/or physical exam in the medical record. Additionally, it should be noted that, on an interim basis, CMS is revising their policy to specify that the 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. It remains CMS’ expectation that providers will document E&M visits as necessary to ensure quality and continuity of care. These policy changes only apply to office/outpatient visits furnished via Medicare telehealth, and only during the Public Health Emergency (PHE) for the COVID-19 pandemic. It is strongly recommended to work with your coding/compliance team to ensure that language required by all payers is included in the documentation to ensure timely payment.

Can I bill an E&M service for telephone calls to patients?

Yes, there are CPT codes to support telephone E&M service, with the understanding that two-way audio-visual technology may not be available. Briefly, they are described as follows (see CPT® for full descriptors):

99441 :  Telephone E&M, for an established patient, 5–10 minutes

99442 :  Telephone E&M, for an established patient, 11–20 minutes

99443 :  Telephone E&M, for an established patient, over 21 minutes

These codes are only reportable when providing E&M services to an established patient and cannot be reported within 7 days of a previously provided E&M service or within 24 hours of a procedure. During the PHE, CMS has established that these codes can be used for new patients.

Is responding to a patient’s electronic message billable?

Yes, CPT codes  99421 – 99423  can be used when a provider responds to a  patient generated  electronic inquiry. These E&M services do not use interactive audio or visual. As with other non-face-to-face E&M services, the codes are time based and are cumulative over a 7-day period; which begins when the provider reviews the initial patient generated inquiry. The time includes review of patient’s medical records, the time to perform medical decision-making, develop a plan and place orders, as well as the time for communication back to the patient. Permanent documentation should support the time and effort taken, including documentation of the time in minutes spent performing these activities. The codes may not be used for work done by clinical staff and should not be billed if/when other E&M services are provided within the past 7 days. During the PHE, these codes can be used for new patients or established patients. 

99421 :  Online digital E&M service, for an established patient, for up to 7 days cumulative time during the 7 days; 5 – 10 minutes

99422 :  Online digital E&M service, for an established patient, for up to 7 days cumulative time during the 7 days; 11 – 20 minutes

99423 :  Online digital E&M service, for an established patient, for up to 7 days cumulative time during the 7 days; 21 or more minutes

Disclaimer:  SIR is providing this billing and coding guide for educational and information purposes only. It is not intended to provide legal, medical or any other kind of advice. The guide is meant to be an adjunct to the American Medical Association’s (AMA’s) Current Procedural Terminology (2020/CPT ® ). It is not comprehensive and does not replace CPT. Our intent is to assist physicians, business managers and coders. Therefore, a precise knowledge of the definitions of the CPT descriptors and the appropriate services associated with each code is mandatory for proper coding of physician service.

Every reasonable effort has been made to ensure the accuracy of this guide; but SIR and its employees, agents, officers and directors make no representation, warranty or guarantee that the information provided is error-free or that the use of this guide will prevent differences of opinion or disputes with payers. The publication is provided “as is” without warranty of any kind, either expressed or implied, including, but not limited to, implied warranties or merchantability and fitness for a particular purpose. The company will bear no responsibility or liability for the results or consequences of the use of this manual. The ultimate responsibility for correct use of the Medicare and AMA CPT billing coding system lies with the user. SIR assumes no liability, legal, financial or otherwise for physicians or other entities who utilize the information in this guide in a manner inconsistent with the coverage and payment policies of any payers, including but not limited to Medicare or any Medicare contractors, to which the physician or other entity has submitted claims for the reimbursement of services performed by the physician.

*The content and guidance described in this article was current at the time it was written. Due to the nature of the recent PHE,  payment policy is likely to change rapidly and may vary geographically.  Members should continue to follow and consult local/national payer guidelines for most up-to-date guidance. Also refer to SIR’s telehealth information within the COVID-19 Toolkit:  bit.ly/2YcQz4u .

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Coding Telemedicine Visits for Proper Reimbursement

Gary n. gross.

Internal Medicine, Southwestern Medical Center, University of Texas, Dallas, TX USA

Purpose of Review

Coding for patient visits and monitoring via telehealth have expanded over the past years with a wide acceptance of telemedicine as a consequence of the coronavirus pandemic. Coding topics of interest to the allergist/immunologist in regard to services provided via telemedicine will be of increasing importance in the coming years.

Recent Findings

CPT coding for telephone as well as synchronous face-to-face telehealth visits has changed over the past few years. With the need for distancing and patient protection during the coronavirus pandemic, telehealth services have increased dramatically. The introduction of newer devices to remotely monitor patients will increase and be incorporated into patient care.

This review will summarize current codes available for designating what services have been provided. The area of telemedicine is changing and will continue to evolve as other platforms for visits are designed and other methods of monitoring patients become available. Coding for these services will be an ongoing need for the provider.

Introduction

Current procedural terminology (CPT) has recognized the need for designations of procedures done using technology. Although initial codes focused primarily on telephone visits, in 2017, CPT recognized a new place-of-service (POS) code designating “The location where health services and health related services are provided or received, through a telecommunication system.” This POS “02” was a step forward in awareness of the need for distant patient encounters and procedures. Further codes for both monitoring and evaluating via telehealth will be discussed. Table ​ Table1 1 lists current CPT codes available for designating services provided.

Current CPT codes [ 1 ]

Telehealth Coding

Two words must be remembered whenever coding is discussed. The two words, “it depends,” define the lack of consistency in coding throughout the industry. Coding is generally driven by The Centers for Medicare & Medicaid Services (CMS) and CPT (although they do not always align). CPT codes exist for procedures, but some carriers may not recognize or reimburse for the codes [ 2 ]. Some carriers may create their own limits on reimbursing for codes, arbitrarily considering procedures bundled with evaluation and maintenance (E&M) visits. Codes may be paid for certain disease states but not for others. Insurers vary with regard to expectations of what place-of-service to use or how to bill for some procedures. New modifiers for telehealth visits further complicate billing. The modifiers –GT and -95 are used by some carriers for telehealth visits and vary depending on the insurer. Similarly, place of service may be either “02,” the telecommunication POS mentioned above, or remain “11” which designates the office location. Therefore, one must be flexible and informed. Keeping track of each carrier’s latest provider information and appealing denials with alternative codes may be necessary.

As with conventional patient encounters, documentation is key. For telehealth visits, there is also the need to document the patient’s consent for the encounter via telehealth. Most of the telehealth codes are for providers who could bill for evaluation and management (E/M) services such as physicians, physician assistants (PAs), and nurse practitioners (NPs). These providers are considered qualified healthcare providers (QHP).

Non-face-to-face Telehealth Patient Visits

Telephone services (99441–99443).

These codes are non-face-to-face E/M services used by QHP. They are designed for telephone calls initiated by an established patient and have certain restrictions. If the call includes the decision to see the patient in the next 24 h or next available urgent appointment, it cannot be billed. Similarly, if the call refers to an E/M service reported by the QHP within the past 7 days, the telephone codes cannot be used. Thus, these calls are initiated by the patient or guardian of the patient and stand apart from other E/M visits as described.

• 99441 - 5–10 min of medical discussion
• 99442 - 11–20 min of medical discussion
• 99442 - 11–30 min of medical discussion

An established patient, who has not been seen in the past month, calls the office because of a recent ant bite. The patient wants to speak to the physician since the physician also treats the son for anaphylaxis to wasps and the patient is concerned. The physician talks to the patient about the kinds of reactions that might occur and notifies him of what symptoms he should be aware of. Out of an abundance of caution, the physician reminds the patient about using an epinephrine autoinjector. The conversation takes 25 min. The staff calls in the autoinjector to the pharmacy and is on the phone for 15 min waiting for the pharmacist.

The patient is billed 99443 for the physician time. The staff time would not enter into the total time. The note in the chart would document that the visit was via telephone and that the patient called the clinic about the problem. The discussion would be documented and the note would indicate the patient had not been seen and no E/M visit was anticipated. The note would also indicate that 25 min was spent in discussion.

Online Digital Evaluation and Management Services (99421–99423)

These codes are electronic communication codes. The problem may be new to the physician or QHP but the patient must be established. These services are patient-initiated through HIPAA-compliant secure platforms or portals.

These services include evaluation, assessment, and management of the patient.

These services are reported once during a 7-day period and therefore time is cumulative.

The time includes (1) review of the initial inquiry, (2) review of patient records or data pertinent to assessment of the patient’s problem, (3) interaction with clinical staff focused on the patient’s problem and development of management plans, (4) physician or other QHP generation of prescriptions or ordering of tests, and (5) subsequent communication with the patient through online, telephone, email, or other digitally supported communication, which does not otherwise represent a separately reported E/M service.

These services require permanent documentation storage (electronic or hard copy) of the encounter.

If within 7 days of the initial patient-initiated contact a separate E/M visit (in person or synchronous telemedicine) occurs, then the Online Digital visit is not billed but the time is incorporated into the subsequent E/M visit. If the Online Digital visit is initiated within 7 days of a previous E/M visit for the same or related problem, the Online Digital visit is not reported. If a new or different problem is being addressed in the Online Digital visit, then the visit is billable and should be reported.

• 99421-5–10 min (over a 7-day period)
• 99422-11–20 min (over a 7-day period)
• 99423-21 or more minutes (over a 7-day period)

Remember that only physician or other QHP time is used in the calculation. Staff time is not included.

An established patient who was seen 3 days ago for allergic rhinitis wakes up with hives. She uses the practice’s HIPAA compliant portal to message her doctor about the hives. The PA responds to the message and gathers information about the hives, the patient’s activities, and ultimately prescribes an antihistamine. The encounter takes 10 min. Two days later, the patient messages again saying the hives are better but not gone. She wants stronger medicine. The PA responds to the message and offers to prescribe a short course of corticosteroids. The PA describes the possible side effects of the steroids and also tells the patient what should be done if the hives do not clear. The PA spends 12 min with the encounter. The patient does not call back and does not come to the office for the hives. The PA bills the patient 99423 since the sum of the two encounters was 22 min within a 7-day period and the hives were not related to the allergic rhinitis the patient had been seen for 3 days before the hives.

The chart would document that the patient contacted the clinic for a new problem. All time spent by the PA would be documented to support the total time billed. It would be documented that no E/M visit was anticipated for this new problem.

Healthcare Common Procedure Coding System (HCPCS) have 2 levels of commonly used codes. Level 1 codes are CPT codes and level 2 codes are alphanumeric codes. One group of HCPCS codes are “G codes.” The G codes are used to identify professional healthcare procedures and services that would otherwise be coded in CPT but for which there are no CPT codes. Two “G codes” are relevant to telehealth and do not yet have matching CPT codes [ 3 ].

was in the 2019 physician fee schedule and is used for remote evaluation of established patient’s submitted videos or still images. The purpose of the evaluation is to determine whether or not an E/M visit is necessary. It may be billed if the evaluation does not lead to an E/M visit and does not occur within 7 days of a previous E/M visit. To bill for the evaluation, the physician or other QHP must evaluate the image within 24 business hours and follow-up with the patient in the form of a 5–10 min discussion with the patient.

An established patient develops a rash and is uncertain about its cause. The patient sends the physician a picture of the rash. The physician evaluates the photo and determines it is a hive. The physician calls the patient and tells him that these are common and if they last more than 6 weeks or get worse he can check back, but that he does not need to have an E/M visit.

Documentation of this remote evaluation would include the picture in the chart and the provider’s note that the picture was viewed and that no visit would be necessary unless the hives lasted more than 6 weeks. The presumed diagnosis of acute urticaria would also be included.

was also included in the 2019 physician fee schedule. It has been referred to as a “virtual check-in.” It is considered to be a call or video check in to see if an E/M visit is needed. Similar to some other e-codes, it cannot be billed if there was a related E/M service within the previous 7 days or it leads to an E/M visit within the next 24 h or soonest available appointment. The code is used for established patients having direct interaction with the billing practitioner (not the staff). The service must be medically reasonable and necessary but there is no limitation on frequency. The code assumes 5–10 min of medical discussion.

An established patient calls the nurse practitioner and describes a large, local reaction they have from a mosquito bite. The patient wants to know if they need to come in or go to the ER. The nurse practitioner informs the patient about the type of reaction and tells the patient they only need to come in if they have trouble breathing or if the reaction spreads. The patient is reassured and watches the reaction as it gradually goes away. The practitioner can bill G2012.

The documentation for this virtual check in would include the main points of discussion including the bite and the likely diagnosis as well as the 5+ min the provider is on the platform talking with the patient.

Face-to-face Telehealth Patient Visits

The Centers for Medicare & Medicaid Services (CMS) defines telehealth services to include those services that require a face-to-face meeting with the patient. These are visits commonly considered “office visits” but delivered via synchronous audio and video contact with the patient. The usual E/M visit codes (99201–99215) would apply.

Prior to 2021, these E/M visits level of service was determined by history, physical exam, and medical decision-making as documented in the CPT book each year. If more than 50% of the face-to-face time with the patient and/or family was used in counseling and/or coordination of care, time becomes the key factor in determining level of service.

Beginning with CPT 2021, time alone may be used to select the appropriate level for the office or other outpatient E/M services codes (99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215). This “time” requires a face-to-face encounter with the physician or other QHP. Time spent with staff such as registering in the office or making future appointments is not used in the calculation of time. Also, note that the new patient level one code (99201) has been deleted.

Medical decision-making (MDM) includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option. Beginning in 2021, MDM may be used independently in establishing a level of service (without consideration of history or physical exam as was required previously). These changes were designed to reduce duplication and unnecessary, repetitious documentation, and should also make coding for telehealth E/M visits easier.

The telemedicine E/M visits are coded just as an in-office E/M visit would be but possibly with the addition of a modifier or a different place of service code depending on the insurance company. Some provisions for telemedicine have been waived during the pandemic to allow more patients access to medical care and to avoid exposure to others in waiting rooms and offices. The telemedicine waivers include evaluation of new patients via telehealth, beneficiaries living in any geographic area and accessing telemedicine from their homes, and use of smartphones and audio only connections for some services. Whether all these waivers will remain in place following the pandemic is unknown.

An established patient calls the office to set up an appointment and is offered a telemedicine option. The patient finds this attractive since it will save him time in traffic and reduce his time away from work. It is for a follow-up to see how he is doing after starting immunotherapy a month ago. The patient signs into the doctor’s telehealth platform and gives verbal consent for the visit. They discuss symptoms, reactions to injections, medications, and concerns of the patient regarding future injections if he goes on vacation. The face-to-face time with the physician is 22 min and the code billed is 99213 (less than the minutes currently typical for 99214 and within the 20–29 min designated for 2021).

These telemedicine visits will require documentation similar to in-person visits. They will include the notation that the patient consents to the telehealth visit. Since the visits for new patients require physical examinations, the best way to document and bill these visits will be based on time. Until 2021, the notation that over 50% of the time with the patient was related to counseling and/or coordination of care is also needed. For follow-up visits before 2021, only two major components of the E/M visit are necessary, so history and medical decision-making with documentation could be used. It may be easier since most telemedicine visits are largely counseling and coordination of care, to base these encounters on total time also and indicate that greater than 50% was devoted to counseling/coordination of care. Typical documentation will include the consent for the visit, the discussion with the patient, the differential diagnosis, the plan of care, and the total “face-to-face” time spent on the visit. The further notation that > 50% of the time was related to counseling and coordination of care (assuming it was) should also be documented.

Remote Monitoring

In addition to patient encounters whether non-face-to-face or face-to-face, the allergist/immunologist may also do remote monitoring of the patient. The 2020 CPT book lists the following codes for remote patient monitoring (RPM). Although some requirements for telehealth services have been modified during the pandemic, RPM services have never been limited by geography to rural or medically underserved areas, nor is there any “originating site” restriction for RPM services. In fact, RPM services can be provided anywhere the patient is located, including at the patient’s home.

• 99453 Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment
• 99454 Device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days (provided monitoring occurs at least 16 days during the 30-day period)
• 99457 Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 min.
• 99458 Each additional 20 min

As more devices become available to monitor asthma and other diseases treated by the allergist/immunologist, these codes will become more widely used just as blood pressure monitoring and diabetes monitoring are today.

An established patient is in the office and has poorly controlled, moderately severe persistent asthma. You provide the patient with a home spirometer that will transmit the FEV1 and FVC to your office. The patient is instructed on how to set up and use the device. He provides data via the portal for 20 days of the next month and you and your staff retrieve the data and analyze it. The time involved in retrieving and analyzing the information is 18 min. You modify the patient’s treatment program and describe the new treatment program during a telemedicine visit.

Billing would be 99453, 99454, and 99457 (each one unit). The E/M visit would be billed based on the time spent with the patient in describing the new treatment plan.

The documentation for these services might include a statement such as “we have provided this patient a remote spirometer and taught the patient its proper use. The patient has used it and transmitted information to us 20 days this month and the staff and I have spent 18 min total in the monitoring and responding to this patient in regard to asthma management based on results of the information transmitted.”

An older CPT code used for remote patient monitoring is 99091. This older code requires 30 min to bill based on a 30-day period. It is also limited to physicians and QHPs. There must be a face-to-face visit within 1 year and consent must be given and documented. The platform used must both collect and transmit data in real time or near real time to be eligible.

Another set of spirometry codes (94014, 94015, 94016) relate to patient-initiated remote spirometry, transmission of tracings, and review and interpretation by a physician or QHP. The second code (94015) does not include review and interpretation by a physician or other QHP whereas the third code (94016) is the review and interpretation by the provider. 94014 is an inclusive code of the latter two.

Interprofessional Telephone/Internet/Electronic Health Record Consultations

Codes 99446, 99447, 99448, 99449, and 99451/99452 are used to report a consultation when there is an interprofessional electronic consultation regarding assessment and management of a patient who is not seen face-to-face by the consulting provider. The patient may be a new patient to the consultant or an established patient with a new problem. The patient should not have been seen by the consultant for a face-to-face encounter in the past 14 days. Similarly, there should not be a transfer of care or a face-to-face encounter within the following 14 days of the consultation. Greater than 50% of the time for service must be devoted to the verbal or internet discussion. These codes should not be reported more than once within a 7-day interval. The consulting provider delivers a written or verbal report to the patient’s treating provider. The patient or family must give verbal consent (documented in the record) for the consult.

• 99446 reported by the consulting provider for 5–10 min of consultative discussion/review
• 99447 11–20 min
• 99448 21–30 min
• 99449 31 min or more

Code 99451 is reported by the consultant for 5 min or more time but does not require that more than 50% of the time be consultative time as opposed to data review. Furthermore, 99451 requires a written report.

Code 99452 is billed by the treating/requesting provider. This code is for time spent in preparing the consult and/or time communicating with the consultant for 16 min or more time.

Conclusions

Telemedicine will continue to be a significant part of the allergy/immunology practice even after the pandemic. Both Medicare and commercial insurance companies have made special provisions for telehealth during the pandemic in order to make medical care more readily available for patients who are concerned about their symptoms and also concerned about possible exposure to illness in a healthcare facility. Such provisions as allowing telephone calls (without video) to be sufficient for a “face-to-face” telemedicine visit for patients who do not have access to computers or other means of communicating via video connections will probably not continue after the pandemic [ 3 , 4 ]. The leniency on what platforms can be used by practices for telehealth visits will also likely change after the pandemic. These possible changes will likely be rolled out at different times for different carriers so it will be critical to review EOBs and look at insurers’ websites and newsletters.

It will be important to learn the codes and understand what codes different insurers require in order to be properly reimbursed for your work. Remembering to get consent for visits, to document what was done, to adhere to procedures that are medically necessary, and to code correctly will help practices receive payment for these services. It would be helpful to medicine in general if the commercial insurance companies and CMS provided a uniform approach and guideline for telemedicine coding. Until such time that these stakeholders provide a consistent and uniform coding guide to telemedicine, remember that “it depends” as you select the appropriate code, modifier, and place of service for telemedicine encounters.

Compliance with Ethics Guidelines

The authors declare no conflicts of interest relevant to this manuscript.

This article does not contain any studies with human or animal subjects performed by any of the authors.

This article is part of the Topical Collection on Telemedicine and Technology

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Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Billing and coding Medicare Fee-for-Service claims

Read the latest guidance on billing and coding Medicare Fee-for-Service (FFS) telehealth claims.

On this page:

Telehealth codes covered by medicare, coding claims, common telehealth billing mistakes, more information about ffs billing.

Medicare added over one hundred CPT and HCPCS codes to the list of telehealth services .

Telephone visits and audio-only telehealth

Medicare is temporarily waiving the audio-video requirement for many telehealth services. Codes that have audio-only waivers are noted in the list of telehealth services .

Place of Service codes

When billing telehealth claims, it is important to understand the place of service (POS) codes as it affects reimbursement.

The POS code (PDF) explains where the provider and patient are located during the telehealth encounter. There are currently two POS codes:

• POS 02: Telehealth provided other than in patient's home. Patient is not located in their home when receiving health services or health related services through telecommunication technology.
• POS 10: Telehealth provided in patient's home. 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.

Avoiding mistakes in the reimbursement process can help implementing telehealth into your practice a smoother experience.

Incorrect billing codes

More than 100 telehealth services are covered under Medicare. However, some CPT and HCPCS codes are only covered temporarily.

Using the wrong code can delay your reimbursement. This can happen for a variety of reasons, such as a misunderstanding of what code applies to what service or input error.

Stay up to date on the latest Medicare billing codes  for telehealth to keep your practice running smoothly.

Documentation

Post-visit documentation must be as thorough as possible to ensure prompt reimbursement.

While there are many similarities between documenting in-person visits and telehealth visits, there are some key factors to keep in mind.

Patient consent

Make a note of whether the patient gave you verbal or written consent to conduct a virtual appointment.

Code categories

Telephone codes are required for audio-only appointments, while office codes are for audio and video visits.

Time of visit

A common mistake made by health care providers is billing time a patient spent with clinical staff. Providers should only bill for the time that they spent with the patient.

Store-and-forward

Many states require telehealth services to be delivered in “real-time”, which means that store-and-forward activities are unlikely to be reimbursed. You can find information about store-and-forward rules in your state here  .

Originating sites and distant sites

Learn about eligible sites as well as telehealth policies specific to Federally Qualified Health Centers and Rural Health Clinics.

If you are looking for detailed guidance on what is covered and how to bill Medicare FFS claims, see:

• Billing for Telehealth Encounters: An Introductory Guide on Fee-for-Service  (PDF) – from the National Policy Center - Center for Connected Health Policy

Medicaid and Medicare billing for asynchronous telehealth

Learn how to bill for asynchronous telehealth, often called “store and forward".

Billing Medicare as a safety-net provider

Medicare billing and coding guidelines on telehealth for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs).

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June 28, 2024

Coding for Telehealth

The Future of Telehealth and Virtual Care Valerie Rock, CHC®, CPC® – Principal, Healthcare Consulting Katie M. Baker, MSHA, CPhT – Manager, Healthcare Consulting

Introduction to Telehealth

The concept of telehealth has been around for many years, and, prior to the COVID-19 pandemic, it was used relatively sparingly by some providers and healthcare organizations who needed to meet the needs of patients who were in geographically distant locations. When the COVID-19 pandemic started in March of 2020, healthcare organizations were faced with the challenge of providing a high volume of services while simultaneously working through facility capacity constraints and quarantine protocols. As such, telehealth became a vital part of care delivery, allowing patients to be seen and treated within their homes by a multitude of healthcare providers. While the PHE has ended, the prevalence of telehealth shows no signs of slowing down. Telehealth has proven to be beneficial for increasing patient access; however, it comes with its own set of complexities related to compliant billing, collections, and administration.

Pre-COVID Medicare Telehealth Coverage

Prior to the start of the COVID-19 public health emergency (PHE), the Centers for Medicare & Medicaid Services (CMS) had some general requirements related to telehealth coverage. As outlined in Section 1834(m) of the Social Security Act [1] , coverage for telehealth services must have met the following criteria:

• Geography – The patient must have resided in a rural area.
• Location – The patient must have been physically present at a healthcare facility when the service was provided (with associated facility fee billed).
• Service – Coverage was limited to CMS’ list of approved telehealth services.
• Provider – Services must have been provided by a physician, non-physician practitioner, clinical psychologist, clinical social worker, registered dietician, or nutrition professional.
• Technology – Services must have been provided via telecommunications technology with audio and video capabilities that permitted real-time, interactive communication.

Despite the coverage requirements above, there were some exceptions, including:

• Telestroke services, which had their geographic and location requirements waived effective January 2019 for those services furnished to diagnose, evaluate or treat symptoms of acute stroke;
• End-stage renal disease (ESRD) services, which also had their geographic and location requirements waived effective January 2019 for those services relating to home dialysis;
• Substance use disorder (SUD) services, which had their geographic and location requirements waived in July 2019 for those services relating to SUD and/or co-occurring behavioral health conditions;
• Services billed to Medicare Advantage plans, as, beginning in the 2020 plan year, Medicare Advantage plans were permitted to begin waiving geographic and location requirements if required; and
• Services billed by organizations participating in down-side risk models for the Medicare Shared Savings Program (MSSP) or Center for Medicare and Medicaid Innovation (CMMI) initiatives.

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Including updates on CPT ® and CMS coding changes for 2024

Medicare Telehealth Coverage Expansion During PHE

As a result of the COVID-19 PHE, CMS elected to expand telehealth coverage to allow greater access for patients and remove barriers to care related to capacity constraints within healthcare facilities. Legislative action allowed the Secretary of the Department of Health and Human Services (HHS) to waive Section 1834(m) geography and location requirements for the duration of the PHE.

CMS also issued interim final rules that suspended certain service restrictions for the duration of the PHE as well. This included an expanded list of covered services, the elimination of frequency requirements, and permitted use of telehealth for previously required face-to-face visits, direct supervision for incident-to-billing, and teaching physician presence. Certain provider restrictions were also suspended, as CMS waived the state licensure requirement [2] , permitted therapists and speech language pathologists to provide covered services via telehealth, permitted FQHCs and RHCs to bill for telehealth services under Healthcare Common Procedure Coding System (HCPCS) code G2025, and permitted billing for hospital outpatient department and critical access hospital services furnished via telehealth.

The interim final rules issued also authorized payment for certain audio-only evaluation and management (E/M) services (Current Procedural Terminology (CPT®) codes 98966-68, 99441-43) and provided reimbursement for telehealth services at higher non-facility rates to compensate practices for telehealth-associated costs.

In order to assist with the provision of service during the pandemic, other agencies followed suit and waived or suspended certain restrictions.

• The Office for Civil Rights (OCR) issued a Notice of Enforcement Discretion, stating they would not impose penalties if, in good faith, an organization used any non-public remote audio/visual communication product.
• The Office of Inspector General (OIG) also issued a Notice of Enforcement Discretion that permitted the waiver of co-insurance for associated services.
• The Drug Enforcement Administration (DEA) permitted the use of telehealth for in-person medical evaluation prior to prescribing scheduled II – V controlled substances.

As you can see, there was sharp increase in the number of telehealth users in Q2 of 2020, with nearly half of Medicare beneficiaries having at least one telehealth service during that time. The utilization has continued to level off, with total telehealth users dropping to 3.3M in Q4 of 2022; however, the 3.3M users is still well above the 1.6M in Q1 of 2020. [3]

Tele-Behavioral Health Services

Behavioral health services continue to be an exception to the rule. Through the Consolidated Appropriations Act (CAA) of 2021, geographic and location restrictions for diagnosis, evaluation, and treatment of mental health disorders were permanently waived. Patients must have an in-person, non-telehealth service by a practitioner in the same practice as the billing practitioner within the six months prior to the initial telehealth service and each twelve months thereafter. [4] There are some exceptions to the in-person visit requirement based on beneficiary circumstances (with reason documented in beneficiary’s medical record). Audio-only communication technology is permitted (as opposed to audio and video for other telehealth services) but only if the practitioner has audio and video capability and beneficiary lacks capacity or refuses to use video connection. This must be documented in the medical record and include a service-level modifier on the claim.

Extension of Flexibilities

Although the COVID-19 PHE has ended, many CMS flexibilities around telehealth coverage have been extended through December 31, 2024. These include:

• The continuation of the waiver of geographic and location requirements;
• The continuation of reimbursement for physical therapy, occupational therapy, speech language pathology, and audiologist telehealth services [5] ;
• The continuation of reimbursement for audio-only E/M CPT® codes (99441-43) and specified behavioral health and education services;
• A delay in the in-person requirement for initiation of tele-behavioral health services [6] ;
• The continuation of reimbursement to FQHCs and RHCs for medical telehealth services through CPT® code G2025; and
• The continuation of the use of telehealth to re-certify eligibility for hospice and required face-to-face encounter for home health.

There are some flexibilities that have not been extended however, including the permission to waive co-insurance for telehealth and virtual services. Additionally, organizations must comply with all HIPAA rules when providing telehealth services on a go-forward basis.

Effective January 1, 2024, organizations are required to begin using place of service (POS) 02 for telehealth provided other than in the patient’s home or POS 10 for telehealth provided in the patient’s home. Organizations may discontinue the use of modifier 95 and POS that would have been selected if the service had been furnished in-person. Additionally, POS 02 is to be paid at a lower facility rate and POS 10 is to be paid at a higher non-facility rate.

Organizations may no longer utilize telehealth for required face-to-face visits for home dialysis or inpatient rehabilitation facility patients; however, remember that for ESRD services, the geographic and location requirements were permanently waived in 2019, meaning this change would be for the required face-to-face visits only. Organizations may also no longer provide resident supervision via telehealth except in instances where the training program is located outside of the metropolitan statistical area (MSA) and the service is being furnished virtually (i.e., via three-way telehealth visit).

Medicare Physician Fee Schedule (MPFS) 2024 Updates

As guidance continues to shift and change post-PHE, there are several key updates resulting from the passage of the 2024 MPFS final rule. One of those includes changes to the covered telehealth services list, replacing Categories 1, 2, and 3 with permanent and provisional categories. CMS is also working to refine the process related to service eligibility for telehealth. At this time, all service categories (vs. Category 3 services only) added to the list during the PHE have been moved to the provisional category and there is no stated timeframe for removing these provisional codes from the list.

In addition to the extension of flexibilities previously noted, the 2024 MPFS Final Rule:

• Suspends frequency limitations for subsequent inpatient visits, subsequent nursing facility visits, and critical care consultations;
• Permanently eliminates the in-person requirement for injection training for Diabetes Self-Management and Training (DSMT) and expands the list of eligible DSMT distant site providers;
• Continues permitting opioid treatment programs to furnish periodic assessments via audio-only communications through the end of 2024; and
• Increases the originating site facility fee (Q3014) from $28.64 to $29.92.

Best Practices for Telehealth

As a result of these extensions and post-PHE changes, organizations should ensure their policies are aligned with current guidance. Additionally, organizations should continue to document E/M services as they would for an in-person visit, including a full patient history, examination, and medical decision making. Providers should also include a statement that the service was provided via telehealth, the HIPAA secure and OCR-approved platform that was used, where the provider and patient were located at the time-of-service delivery, and names and roles of any others participating.

Telehealth is here to stay and there continues to be expansion in the types of services that can be provided via telehealth, as well as the types of providers eligible to provide services via telehealth. In order to ensure you are compliantly billing and coding for telehealth services, consider implementing internal auditing and monitoring processes specific to telehealth to identify opportunities for improvement or additional provider/staff education. Stay up-to-date on telehealth requirements and changes by monitoring CMS resources and seeking additional guidance through webinars and other channels.

About the authors

Valerie serves as a Principal on the Firm’s Revenue and Compliance Advisory Services team, specializing in physician coding, reimbursement, and regulatory compliance. With more than 15 years of experience in healthcare consulting, Valerie has assisted numerous clients with hospital-employed physician compliance and audit program development; physician and laboratory compliance program advisory support; statistically valid, sample-based refunds; physician and non-physician practitioner compliance; Medicare and Medicaid regulatory compliance and reimbursement methodologies; and practice establishments and operational consultations.

Katie serves as a manager on PYA’s Revenue and Compliance Advisory Services team. Prior to joining PYA, Katie worked as a nationally certified pharmacy technician for more than six years and served as an associate for the Department of Managed Care Contracting at UAB Hospital’s Health Services Foundation. As a manager at PYA, Katie has experience in physician practice operations, revenue cycle and financial controls, physician practice establishment, physician reimbursement, regulatory compliance, and due diligence activities. Katie holds a Bachelor of Science in Management with an emphasis on Healthcare Management and a Minor in Political Science from the University of Alabama. She also holds a Master of Science in Healthcare Administration with an emphasis in Healthcare Finance from the University of Alabama at Birmingham.

[1] https://www.ssa.gov/OP_Home/ssact/title18/1834.htm

[2] While CMS waived the state licensure requirement for Medicare, they did not have the authority to waive broader state laws related to licensure.

[3] https://data.cms.gov/sites/default/files/2022-09/Medicare%20Telehealth%20Trends%20Snapshot%2020220906.pdf

[4] Please note that through December 31, 2024, this in-person visit is permitted to be conducted via telehealth.

[5] CMS has also added marriage and family therapists and mental health counselors to the list of eligible telehealth practitioners.

[6] As noted previously, the CAA of 2021 permanently eliminated geographic and location requirements for tele-behavioral health services subject to certain requirements and provided coverage for those services furnished by Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs).

Last revised May 22, 2024 - Betsy Nicoletti Tags: CMS updates , telehealth

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Abstract: Learned video compression methods already outperform VVC in the low-delay (LD) case, but the random-access (RA) scenario remains challenging. Most works on learned RA video compression either use HEVC as an anchor or compare it to VVC in specific test conditions, using RGB-PSNR metric instead of Y-PSNR and avoiding comprehensive evaluation. Here, we present an end-to-end learned video codec for random access that combines training on long sequences of frames, rate allocation designed for hierarchical coding and content adaptation on inference. We show that under common test conditions (JVET-CTC), it achieves results comparable to VTM (VVC reference software) in terms of YUV-PSNR BD-Rate on some classes of videos, and outperforms it on almost all test sets in terms of VMAF BD-Rate. On average it surpasses open LD and RA end-to-end solutions in terms of VMAF and YUV BD-Rates.

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In the exam room, the distinction between one type of visit and another isn't always clear. It's important to know when — and how — you can bill for both .

BETSY NICOLETTI, MS, CPC, AND VINITA MAGOON, DO, JD, MBA, MPH, CMQ

Fam Pract Manag. 2022;29(1):15-20

Author disclosures: no relevant financial relationships.

In family medicine, it's common for a medical problem to crop up during a routine preventive visit, or for a preventive service to crop up during a problem-oriented visit. For example, let's say you're finishing up a Medicare annual wellness visit when the patient lifts his shirt and says, “Oh yeah, I'd also like you to look at this rash,” which results in a prescription. Or, at a follow-up visit for a patient's chronic condition, you notice he is overdue for a flu shot and colorectal screening, so you perform a preventive visit too.

From a coding perspective, there is a bright line between a preventive medicine visit and a problem-oriented visit. One is for promoting health and wellness, and the other is for addressing an acute or chronic medical problem. But in the exam room, the distinction isn't always clear. The question for family physicians is this: When does the work in the exam room warrant billing for two distinct services?

The answer lies in knowing the requirements for various preventive medicine and Medicare wellness visits, knowing when you've done enough beyond those requirements to also bill for a separate E/M service, and knowing how to document and code it all. The good news is the 2021 E/M coding changes made it easier than it used to be.

When physicians and other clinicians address a medical problem during a preventive or wellness visit, they can often bill for both services.

Knowing the core components of preventive or wellness visits can help physicians recognize when they have done enough work beyond those requirements to bill for a separate evaluation and management service.

Because preventive and wellness visits come with no cost sharing, it's best practice to explain to patients that a separate service performed during the same visit may result in a charge to them.

PREVENTIVE MEDICINE VISITS

Preventive medicine visits (CPT codes 99381-99397) are for patients covered by commercial insurance, Medicaid plans, and some Medicare Advantage plans. Patients value these visits because they are not subject to co-pays and deductibles. After age two, one preventive visit is covered annually.

According to CPT, preventive medicine visits are “comprehensive preventive medicine evaluation and management services of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures.”

Codes 99381-99387 are for new patients and 99391-99397 are for established patients. Both are further broken down by age group. The extent of the exam, the content of the counseling and anticipatory guidance, and the recommended screenings and immunizations vary depending on the patient's age and gender. “Comprehensive” in the CPT definition is not synonymous with the comprehensive exam required in other E/M services. This is a common misconception among physicians and patients alike.

CPT states that if a new or existing problem is assessed and managed at the time of the preventive visit, the physician should also bill a problem-oriented visit (an office visit) on the day of the preventive care. But insignificant problems that do not require extra work should not be billed as office visits. If a patient comes in for a preventive visit and the clinician also looks at a rash or notices the patient's blood pressure is elevated, these observations alone are not enough to bill a problem-oriented E/M visit. There must be some medical decision making (MDM) that occurs, such as prescribing a topical treatment for the rash or choosing not to prescribe a medication for the high blood pressure and instead suggesting the patient change his diet.

Once you've documented your MDM, you can bill an E/M visit using codes 99202-99215 with the preventive medicine visit code. Make sure to add modifier 25 to the E/M code to signal to the payer that two distinct visits were done on the same day.

For more details on when to bill both visits, how to level the E/M portion, and what to include in your documentation, see “ One visit or two? ”

ONE VISIT OR TWO?

Medicare wellness visits.

Original (traditional) Medicare does not cover CPT codes 99381-99397, because Medicare has its own wellness visits with their own “G” codes and requirements. As mentioned, some Medicare Advantage plans do cover the preventive medicine CPT codes in addition to Medicare wellness visits. However, a Medicare wellness visit and a preventive visit should not be billed on the same date of service. Medicare developed the Initial Preventive Physical Examination (IPPE, also known as the “Welcome to Medicare” visit) (G0402) and initial and subsequent annual wellness visits (G0438 and G0439) to encourage Medicare patients to receive screenings and preventive care, and to work with their physicians to develop a personalized prevention plan. 1 The requirements are slightly different for the three codes, but in general they require collecting or updating medical, family, and social history; screening for depression; evaluating the patient's ability to perform activities of daily living; assessing the patient's safety at home; recording vital signs; asking about opioid and substance use; and providing guidance about preventive services and a personalized prevention plan (for more details, see the table in “ Medicare 101: Navigating the Rules for Coverage and Benefits in Clinical Practice ”). Similar to CPT's preventive medicine visits, Medicare wellness visits do not require a full head-to-toe physical exam.

The assessment and management of acute or chronic problems are not components of the IPPE or annual wellness visits. When that service is medically necessary during a Medicare wellness visit, the physician can also bill for a problem-oriented E/M office visit on the same day, again using the appropriate CPT code (99202-99215) with modifier 25.

SELECTING THE LEVEL OF SERVICE FOR THE E/M CODE

Hopefully you're now familiar with the E/M coding rules that changed in 2021. 2 Performing a problem-oriented E/M service on the same date as a wellness visit adds a layer of complexity when it comes to choosing the level of service for the E/M code. But, as mentioned, the new rules actually make it easier than it was before.

When selecting a code (99202-99215) using the new E/M guidelines for office and outpatient services, physicians may use either total time on the date of the visit or MDM. History and exam are no longer necessary to select the level of service (though they should still be documented to provide the best care). This makes it easier to select a level of service for the problem-oriented visit when it's combined with a wellness or preventive visit because there are fewer overlapping components when coding based on MDM. The E/M service is your assessment and management of an acute or chronic condition, which is not required in either CPT preventive services or Medicare wellness visits.

It's trickier to code the E/M service based on time because you must make sure to only count the time spent managing the problems, not the time spent on the preventive or wellness service. The February 2021 CPT Assistant newsletter was particularly clear on this, stating “if time is used for selection of a level of the office/outpatient E/M code, the time spent on the preventive service cannot be counted toward the time of the work of the problem assessment because time spent performing a service cannot be counted twice. The code for the problem-assessment portion of the encounter will likely be selected based on MDM.” 3 It might make sense to consider MDM-based coding as the best practice when combining E/M visits with wellness visits.

A problem-oriented visit includes the history of the problem and any symptoms or complaints related to it. It may or may not include a physical exam or data review (e.g., notes reviewed, tests ordered, tests reviewed, or independent historian). It includes the evaluation and management of a problem or condition. When these components are documented in addition to the preventive visit, add a problem-oriented visit code. For more on which components are required for which visits, see “ How to credit combined visits .”

Let's look at some examples of when it would be appropriate to bill for a problem-oriented E/M code (CPT 99202-99215) along with a preventive or wellness visit.

Patient 1: A 70-year-old male, established patient with a history of diabetes and hyperlipidemia comes in for a Medicare annual wellness visit. All required components of the wellness visit are completed. The patient then asks for a refill of his diabetes medication. The physician asks the patient if he is taking his medication as prescribed and following the diet recommendations discussed during the last visit. The physician also performs a focused physical exam, discusses medication management for diabetes and hyperlipidemia, and orders maintenance labs. The physician documents her significant review of the patient's problems, bills for the annual wellness visit with code G0439, and adds a 99214 E/M code because she addressed two stable chronic illnesses and performed prescription drug management. She adds modifier 25 to the E/M code.

Patient 2: A 32-year-old female, new patient comes in for a preventive medicine visit required by her employer. The physician completes all requirements for the preventive visit. During the history portion, the patient tells the physician that she has been having some knee pain exacerbated by running. The physician obtains additional history about the pain, examines her knee, tells her to reduce her running until the pain subsides, and gives her a handout on knee exercises. He also recommends she try a knee brace and follow up if the pain does not lessen with rest. The physician documents the extra work done to address the knee issue, then bills code 99385 for an initial preventive medicine visit for a patient age 18–39, along with E/M code 99203 because he addressed one acute, uncomplicated injury. He adds modifier 25 to the E/M code.

Patient 3: A 49-year-old female, established patient comes in for her annual preventive visit. The physician completes all requirements for the preventive visit. The patient then mentions she has been excessively tired recently and has been having trouble sleeping. The physician obtains a detailed history of the problems, does a thorough physical exam, and orders some labs (complete blood count and thyroid-stimulating hormone). The physician documents the extra work, then bills code 99396 for a periodic preventive medicine visit for a patient age 40–64 and E/M code 99213 for addressing two acute illnesses (fatigue and insomnia) and ordering two labs. The physician adds modifier 25 to the E/M code.

WORKFLOW TIPS

It's hard to plan for surprise problems that come up during a preventive or wellness visit. But your staff can help by asking patients up front if they have any other issues that need to be addressed. This step should occur when staff are scheduling or confirming patient visits, allowing you to block off more time if necessary.

Scheduling staff should also be aware that Medicare wellness visits have strict rules about how often they can be billed. They must be separated by at least 12 months from the previous wellness visit. Having staff check eligibility for Medicare wellness visits using the HIPAA Eligibility Transaction System can help you avoid denials. 4 The timeframes for CPT preventive visits are more forgiving; they can be performed once every plan year (usually a calendar year, but some plans vary).

Patients who know their preventive/wellness visit will be covered with no deductible or co-pay may mistakenly assume all services provided during that visit, including E/M, will be no cost to them. It is best to educate patients on the costs associated with a problem-oriented office visit and let them know that performing one with a preventive or wellness visit will result in the same co-pay they would incur if the problem-oriented visit was on a different day. Most patients will accept this, because getting both visits in the same trip is more convenient for them. Posting flyers in the exam rooms or waiting room about the difference between preventive/wellness visits and problem-oriented visits, and the costs associated with each, can also prevent patient dissatisfaction.

Physicians could ask these patients to return for the problem-oriented visit on another day, but if time allows for providing both services at the current visit, it is only fair and reasonable to do so. Knowing the rules for combined visits, and the convenience they offer patients, should give physicians the confidence to bill fully for their services.

The ABCs of the Initial Preventive Physical Examination. Medicare Learning Network. Accessed Nov. 15, 2021. https://www.mvphealthcare.com/wp-content/uploads/download-manager-files/CMS-ABC-Initial-Preventive-Physical-Examination-ICN006904-01-2015.pdf

Millette KW. Countdown to the E/M coding changes. Fam Pract Manag . 2020;27(5):29-36.

Evaluation and management (E/M) 2021; AMA CPT Assistant . 2021;2:7-8.

HIPAA Eligibility Transaction System (HETS). Centers for Medicare & Medicaid Services. Updated Oct. 25, 2021. Accessed Nov. 15, 2021. https://www.cms.gov/research-statistics-data-and-systems/cms-information-technology/hetshelp

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