Telehealth FAQ: You Asked, We Answered

Telehealth FAQ: You Asked, We Answered

Certain telemedicine services are already covered under the Physician Fee Schedule (PFS) when provided to Medicare patients in accordance with regulations. In response to the public health emergency (PHE) for the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS) has temporarily expanded telehealth coverage.

Effective March 6, CMS expanded the telehealth benefit under the Section 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act. Under the wavier, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country, including in patients’ homes. Since issuing the Section 1135 waiver, CMS has issued additional waivers and relaxed more regulations pertaining to Medicare-covered entities. Policy changes are outlined in an interim final rule with comment period.

Although there are no new codes associated with the telehealth policy changes (aside from the new COVID-19 diagnosis and testing codes), many medical coding questions remain. Here are some frequently asked questions (FAQ), which we have done our best to answer.

Disclaimer: Information related to COVID-19 is changing rapidly. This information was accurate at the time of writing. Please continue to check payer websites, CMS, CDC, and AAPC’s Knowledge Center for the most up-to-date information.

  1. What code can the PCP bill for specimen collection?

Q: Hello, do you know if the PCP office can bill any codes for the collection of the specimen (swab) of COVID-19 testing? I have a scenario where the PCP office is collecting the swab but then sending the specimen to outside lab for processing. What code can the PCP bill?

A: If the swab is collected during an E/M in-person visit, it is included in the E/M code. If the patient encounter is for just the swab performed at the office or group practice’s testing site, bill CPT® 99211 (add modifier 25 if this occurs the same day as the assessment). If the patient is swabbed at an independent testing site, the testing site bills CPT® 99001. The lab that performs the test bills CPT® code 87635 (for dates of service on or after March 13, 2020) or new HCPCS Level II codes U0001-U0002 (for dates of service on or after Feb. 4, 2020). Labs may bill U0002 for tests described by 87635 until it is implemented.

For the PHE for the COVID-19 pandemic only, CMS will allow a specimen collection fee for sputum collection performed by trained laboratory personnel. CMS is establishing two new HCPCS Level II codes: G2023-G2024.

COVID-19 tests that allow patients to collect the specimen themselves are not eligible for the specimen collection fee.

  1. Are telephone calls a telehealth service?

Q: For the covered Medicare telehealth visits that are being billed as a 99201-99205 or 99211-99215, it states that the telecommunication systems is audio and video. I just want to clarify that if our providers only speak with the patient on the telephone with no video link set up, does that mean we can only bill for the virtual check-ins and not an OV code? The providers usually spend about 20 minutes on the phone during these visits and complete an entire SOAP note besides the vitals section. Basically, I am trying to clarify if in order to bill for a telecommunication visits for Medicare as a normal E/M OV code, does the service have to be audio AND video?

A: CMS states in the interim final rule, “We expect physicians and other practitioners to use the E/M code that best describes the nature of the care they are providing, regardless of the physical location or status of the patient.” In other words, bill the most appropriate E/M code that describes the service rendered. Append modifier 95 to indicate that the service was conducted using telehealth (which is loosely translated during the PHE for COVID-19).

  1. Who may perform telehealth services?

Q: What happens if a fellow or resident performs this service? Can the attending attest?

A: Distant site practitioners who can furnish and get payment for covered telehealth services (subject to state law) include physicians, nurse practitioners, physician assistants, nurse midwives, certified nurse anesthetists, clinical psychologists, clinical social workers, registered dietitians, and nutrition professionals. CMS is allowing physicians to supervise their clinical staff using virtual technologies when appropriate, instead of requiring in-person presence. On an interim basis for the duration of the PHE for the COVID-19 pandemic, CMS is revising their regulations to specify that Medicare may make payment under the PFS for teaching physician services when a resident furnishes telehealth services to beneficiaries under direct supervision of the teaching physician by interactive telecommunications technology. Additionally, Medicare may make payment under the PFS for services billed under the primary care exception by the teaching physician when a resident furnishes telehealth services to beneficiaries under the direct supervision of the teaching physician by interactive telecommunications technology. (MLN Connects Special Edition, March 31)

  1. How do I bill telephone calls without video?

Q: Can you use codes 99421-99423 for telephone calls or does this have to require online portal? In our community they are saying that Medicare is allowing this because of crisis. I can’t find where it says you can use a telephone anywhere with these codes.

A: For the duration of the PHE for the COVID-19 pandemic, Medicare will make separate payment for CPT® codes 98966-98968 and 99441-99443, with work RVUs based on calendar year PFS 2008 rulemaking.

Also, for the duration of the PHE, CMS is extending CPT® 99421-99423 and HCPCS Level II codes G2016-G2062 to new patients who pose an exposure risk. That is the only change to these codes.

  1. When do I use modifier CR for telehealth?

Q: Does modifier CR need to be used in these circumstances on every telehealth visit and check-in visits also?

A: CMS just issued SE20011, to add the following paragraph:
… telehealth claims don’t require the “DR” condition code or “CR” modifier. CMS is not requiring additional or different modifiers associated with telehealth services furnished under these waivers. However, consistent with current rules, there are three scenarios where modifiers are required on Medicare telehealth claims. In cases when a telehealth service is furnished via asynchronous (store and forward) technology as part of a federal telemedicine demonstration project in Alaska and Hawaii, the GQ modifier is required. When a telehealth service is billed under CAH Method II, the GT modifier is required. Finally, when telehealth service is furnished for purposes of diagnosis and treatment of an acute stroke, the G0 modifier is required.

  1. What is the POS for telephone calls?

Q: My provider did a phone call visit and what I am understanding is that I can bill 99441 with POS 02. Is that the right form to bill in this situation?

A: When a physician or practitioner submits a claim for their services, they include a POS code, which determines whether the service is paid using the facility or non-facility rate. CMS is maintaining the facility payment rate for services billed using POS 02 Telehealth.

Under the waiver, however, CMS is instructing physicians and nonphysician practitioners (NPPs) who bill for Medicare services via telecommunications to report the POS code that would have been reported had the service been furnished in person, with CPT® telehealth modifier 95.

  1. How do we bill telehealth without an E/M visit?

Q: We are a specialist group wanting to bill telehealth but do NOT have an online portal. How would we go about billing since they will not be conducting a normal E/M?

A: Telemedicine interactions between practitioner and patient via telecommunication can be divided into four forms of virtual services as defined by Medicare Part B:

  • Medicare telehealth visits
  • Virtual Check-ins
  • E-visits
  • Remote monitoring

CMS states in the interim final rule, “We expect physicians and other practitioners to use the E/M code that best describes the nature of the care they are providing, regardless of the physical location or status of the patient.” Although a device capable of audio and video is usually required, during the PHE for the COVID-19 pandemic, CMS is allowing audio-only devices to conduct virtual check-ins (HCPCS Level II code G2012 or CPT® 99421-99423, depending on payer).

  1. Are psychotherapy sessions billed at the same rate?

Q: Can you enlighten us about 1 hour psychotherapy session both individual and family within the new COVID waiver parameters. We are interested in the rules for all practitioners, clinical nurse specialist, nurse practitioners, social workers and physicians. Are they coded as before and billed at the same rate? If so, then we document where and with whom the session occurred? Is there anything else about coding a billing we need to know?

A: For the duration of the PHE for COVID-19, Medicare Part B pays for office and other outpatient visits, professional consultation, psychiatric diagnostic interview examination, individual psychotherapy, pharmacologic management, and end stage renal disease-related services included in the monthly capitation payment furnished by an interactive telecommunications system when the usual conditions are met, as outlined in the Medicare Claims Processing Manual. (CMS-1744-IFC § 410.78)

  1. Do we bill telehealth via telephone with E/M codes?

Q: We are not set up to bill telehealth, nor are we in a rural area; however, based on the 1135 waiver IF we “call patients via telephone only” do we bill E/M codes (99213, etc.) – with POS 2? And the provider can call from home or office setting, and the patient will be in their home?

A: Coding depends on what the encounter is for and who the payer is. If the qualified healthcare practitioner (QHP) is providing an  evaluation and management (E/M) service via telephone, bill the telehealth E/M codes. If the QHP is providing only a virtual check-in, bill CPT® code 99421-99423 or HCPCS Level II code G2012 (for Medicare).

CMS is waiving distant and originating site restrictions during the PHE for COVID-19 and instructs us to report the QHP’s POS with modifier 95. “We expect physicians and other practitioners to use the E/M code that best describes the nature of the care they are providing, regardless of the physical location or status of the patient,” CMS states in the interim final rule with commend period.

Commercial payer policies may vary.

  1. Does incident-to apply when billing 99212-99215 in POS 02?

Q: I have a question regarding incident-to billing for codes 99212-99215 while patient is home but NPP is in the office providing telehealth services under the direct supervision of a physician. I am not able to find any guidance on this and if incident-to can apply when billing under POS 02.

A: CMS is allowing physicians to supervise their clinical staff using virtual technologies when appropriate, instead of requiring in-person presence.

  1. Can I bill a new patient telephone call without a subsequent face-to-face visit?

Q: Can the providers bill for new patient initial telephone visits, not online video, if it does not lead to a face to face visit within 7 days during this health crisis? I do see the relaxed waiver comments for established patients for telehealth, but I’m specifically looking for initial telephone calls or consults. I apologize if this has been asked and answered.

A: Think of it this way: Could you bill a new patient E/M without a subsequent face-to-face visit before? If so, nothing has changed except that you should append modifier 95 to the non-traditional telehealth code to indicate the service was conducted via telecommunications.

  1. How do I bill non-Medicare patients for telehealth?

Q: Can you tell us how we would bill non-Medicare patients, such as Medicaid or commercial patients, calling in from home and having a telehealth visit with the physician? I work in an FQHC, so we bill encounters.

A: CMS is approving Medicaid Section 1135 waivers for states in response to COVID-19. Check with your state’s Medicaid office for specific guidance. Commercial payers will also be issuing proprietary guidance so please check their websites.

  1. Do I bill E/M and telehealth services separately?

Q: Are you supposed to bill for both CPT® codes on one claim form or is it one or the other? Example: line one- CPT code 99213-95, line two- CPT code 99442; or CPT code 99442.

A: To bill 99441-99443 and an evaluation and management (E/M) service such as 99213, you must follow CPT® guidelines, which state, “If the telephone service ends with a decision to see the patient within 24 hours or next available urgent visit appointment, the code is not reported; rather the encounter is considered part of the preservice work of the subsequent E/M service, procedure, and visit. Likewise, if the telephone call refers to an E/M service performed and reported by that individual within the previous seven days (either requested or unsolicited patient follow-up) or within the postoperative period of the previously completed procedure, then the service(s) is considered part of that previous E/M service or procedure.”

Provided the documentation shows there is no relationship between the 99213 and 99442, you can then bill for both services using modifiers 25 and 95 on the 99213. However, if the 99442 resulted in the 99213 within 24 hours, or if the 99442 was a follow-up to the 99213 within the previous seven days, you can only bill for the 99213 with modifier 95, or with modifier 02 if that is your payer’s preference.

  1. Do I bill a new patient as an established patient for telehealth?

Q: Should the provider bill an established CPT code even if it’s a new patient?

A: Report the code that best describes the service. CMS states in the interim final rule, “While some of the code descriptors refer to ‘established patient,’ during the PHE, we are exercising enforcement discretion on an interim basis to relax enforcement of this aspect of the code descriptors.”

  1. How do we level E/M services provided via telehealth?

Q: While evaluating via telehealth visit, how can one give the levels of 99201 to 99215 without checking the vitals and PE? Should one switch to the telemedicine codes 99441 series given there is some flexibility now?

A: On an interim basis, CMS is revising their policy to specify that the office/outpatient E/M level selection for these services when furnished via telehealth can be based on medical decision making (MDM) or time, with time defined as all the time associated with the E/M on the day of the encounter; and to remove any requirements regarding documentation of history and or physical exam in the medical record. Good practice for 2021!

  1. What are the rates for telehealth codes?

Q: Am I correct in understanding that codes such as 99213, 99214 and 90836 will be paid by Medicare at a lower-than-usual office rate, since they have to be billed as institutional? (As far as I can tell, the office rate is higher than the institutional rate) So essentially, reimbursement will go down? It appears that for 99213/4 and 90836 the payments are like 30% lower.

A: Traditional Medicare telehealth services professional claims should reflect the designated POS code 02 Telehealth, to indicate the billed service was furnished as a professional telehealth service from a distant site. There is no change to the facility/non-facility payment differential applied based on POS. Claims submitted with POS code 02 will continue to pay at the facility rate.

There are no billing changes for institutional claims; critical access hospital method II claims should continue to bill with modifier GT.

Per CMS, “If you are located in, and you reassigned your billing rights to, a CAH [Critical Access Hospital] and elected the Optional Payment Method II for outpatients … the payment is 80 percent of the Medicare PFS facility amount for the distant site service.”

  1. Can chiropractors bill E/M exams via telehealth?

Q: Does the telehealth waiver apply to chiropractors who can bill E/M exams? Will Medicare pay for these services performed by a chiropractor?

A: If you have previously successfully billed Medicare for chiropractic office E/Ms, it would make sense that Medicare would also pay for telehealth E/Ms now. But this question is probably best answered by your MAC, as Medicare chiropractic rules are stricter than most specialties.

  1. What are the documentation requirements for telehealth services during the waiver?

Q: Is there any documentation that says what information clinical staff should document to support the coding of the telehealth visit/e-visit/ or virtual check in?

A: Telehealth services should be documented the same way you would document face-to-face services. You should also add a statement to the effect that the service was provided non-face-to-face, and document the patient’s location, the provider’s location, and the names and roles of anyone participating in the encounter. Note that, on an interim basis, CMS is removing any requirements regarding documentation of history and/or physical exam for telehealth services.

  1. What place of service do I use for commercial payers?

Q: What place of service do commercial payers require. Does BCBS also require POS 2 like Medicare?

A: Most BlueCross BlueShield companies recognize POS code 02 for telehealth. You should check with your specific payer before using it, however, as some may still prefer CPT® modifier 95.

  1. Will I be audited for telehealth services?

Q: Where is it in writing from Medicare that states you can see a new patient? The 1135 waiver only states that HHS will not audit to ensure that such a prior relationship existed for claims submitted during this public health emergency.

A: The actual wording of the CMS fact sheet reads: “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.”

  1. Can nutritionists bill telehealth services?

Q: Are nutritionists codes 97802 and 97803 included under the waiver? Our nutritionist needs to move some of our diabetic patients with other comorbidities to a telemedicine visit.

A: These services are already on the Medicare Telehealth Code List, so they should be eligible for payment.

  1. Can an AWV be conducted via telehealth?

Q: Can an annual wellness visit be done via telehealth?

A: Established patient AWV codes G0438 and G0439 are both on the Medicare Telehealth Code List, so, yes, an AWV can be performed via telehealth. Note these codes generally cannot be billed more than once within 12 months. However, CMS is waiving limitations for many E/M codes during the PHE for COVID-19 pandemic.

The initial preventive physical examination (IPPE) or Welcome to Medicare visit (G0402) is not on the Medicare Telehealth Code List, so it cannot be performed via telehealth.

  1. How do we bill assisted living visits performed via telehealth?

Q: How do we bill assisted living visits via telehealth? I tried 99336-95 with POS 02 and got denials saying missing/incomplete/invalid/inappropriate place of service.

Evaluation and Management – CEMC

A: CPT® 99336 is not on the Medicare Telehealth Code List, so it cannot be performed via telehealth.

Bruce Pegg

Bruce Pegg, MA, CPC-A, An experienced teacher and published author, Bruce has a Bachelor of Arts degree from Loughborough University in England and a Master of Arts degree from The College at Brockport, State University of New York. He is a Certified Professional Coder (CPC®), credentialed through AAPC, specializing in E/M, pediatric, and primary care coding.

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