Billing and coding for Telemedicine and Telehealth are complex and in a constant state of flux. The addition of the changes brought upon by COVID-19 added another layer of confusion to an already confusing situation.
Telemedicine vs Telehealth vs Digital Health
Throughout this blog, you will see terms such as telemedicine, telehealth, and digital health. To help differentiate these terms, the definitions are as follows:
- Telemedicine encounters are visits with a medical provider (MD, DO, NP, or PA).
- Telehealth encounters are visits with nursing, physical or occupational therapists, pharmacists or other allied health professionals to support and add a multidimensional health care approach to the digital encounter.
- Digital Health is an umbrella term used to describe both telemedicine, telehealth, and remote patient monitoring.
Coverage of Telemedicine
Medical billing and coding are two topics of common concern amongst medical providers. They are topics that are minimally covered in school and clinical rotations and are very dynamic.
When COVID started to change some of the billing and coding laws, especially with Medicare and Medicaid, the ability to stay up to date on these codes and their usage is challenging.
Commercial payers tend to follow CMS guidelines but do allow for more leeway than the government payors. Most insurance companies which include government insurance companies, only reimburse for services provided via an audio and visual medium. Depending on the state this can be a live interaction otherwise known as synchronous or store and forward otherwise known as asynchronous.
One of the biggest concerns with using audio-only billing codes is that they will be deleted or not reimbursed by the insurance company if the patient is seen in-person or via audiovisual means within a certain time.
Medicaid has been more flexible with telemedical and telehealth reimbursement, but Medicare has been rigid until COVID. There were strict guidelines about where the patient and provider must be in order for services to be covered and reimbursed. COVID has reduced the blockage in the system that was holding up all users from utilizing telemedical services.
Medicaid and Medicare allow for:
- Specific utilization of remote patient monitoring products
- Telephone check-in codes to be utilized during the coronavirus pandemic to allow providers to build for services addressed over audio-only evaluations
Major Payers Now Cover Telemedicine
As telemedicine’s popularity grows, laws and regulations must continue to improve and allow for coverage of these services.
There has been significant proof that telemedicine services are valid, reliable, and provide a service to the community.
Due to this, several pieces of legislation have been passed not only allowing for these services to be billed and reimbursed but reimbursed at the same rate as an in-person service.
Other services now changed are:
- Billing for remote patient monitoring (RPM)
- Telephone check-in (audio-only services)
- Center for Medicare Services (CMS) having more relaxed guidelines
Specifically, CMS has relaxed their policies about the locations of the patients and providers during telemedical encounters. Previously, the patient’s location had to meet specific requirements (essentially geographic locations that made accessing medical care difficult). COVID-19 also pushed the barriers of state licensure, often allowing providers from bordering states or for some states, any provider willing to provide telemedical care to practice in that state under a temporary license.
Mental health and substance abuse care are now being covered by CMS for telemedical services.
There are statistics that the opioid epidemic has increased by as much as 40% during the past few months while society is fighting the COVID-19 global pandemic. There has also been a big push for Medication Assisted Therapy (MAT) of substance abuse to become a virtual encounter. This previously was an in-person only therapy given the focus of the visit and the medications being prescribed being controlled substances themselves. Federal and state laws have been altered or amended to allow this type of CDS evaluation to be electronic.
Telemedicine Billing Laws Are Changing Due to COVID-19
COVID-19 brought telemedicine, telehealth, and remote patient monitoring to the forefront of the medical field. When the world began to shut down in April of 2020, people still needed to seek care for chronic conditions, sick visits, and of course Coronavirus scares and exposures. The only way the metrics could be monitored was for the patient to complete these measurements themselves and forward them to their provider.
We live in a technologically advanced world, which can be seen as a major factor separating this pandemic from previous. We as a society had the ability to communicate with family, friends, and medical staff in a manner very familiar to us: video chat. With many major hospital systems already going towards telemedicine and other digital services, this pandemic offered the push that many smaller entities needed to make the leap.
State and federal laws and regulations have been significantly relaxed or suspended that previously put up barriers to telemedical and telehealthcare.
You will notice the trend throughout this blog that has shown how many changes have been made due to COVID-19.
Telemedicine Billing Guidelines for Each Payer
Billing guidelines for patients using insurance to pay for the visit requires a front-end receptionist or team who knows and understands digital health. There is also a need for back-end staff who understands the differences between telemedicine, telehealth, and remote patient monitoring and which billing code applies to which service, and how to maximize reimbursement for these services. Different states will have different laws to cover these services and the staff that deals with this material will need an understanding of the variances state-to-state.
The payor’s website, especially the healthcare providers or patient portal, should offer the most information on what services are covered and at what percentage they are covered.
Other factors that are important to assess prior to scheduling a digital health evaluation are:
- Asynchronous (live video) versus synchronous (store-and-forward)
- Restrictions on patient or provider location
- If consent needs to be verbal or written
These are just a few of the many factors that the front-end staff should be well versed in and know their state rules and regulations as well as the general view of the payors utilized by their patient population.
While it is unlikely in this day and age, some payors may also limit which providers can be seen on telemedical platforms (MD and DO vs PA and NP). While PA legislation usually follows their physician supervisors, NP’s tend not to have such specific legislation as readily available.
For company’s like Wheel and others that are cash and carry type business, these rules are a bit more lax. Since they are not going through CMS or a private insurance company, they can bill a specific dollar amount and not have to deal with meeting the payor’s regulations and rules for reimbursement. Of course, they are limited by federal and state laws, but most of these sites work well within these regulations.
Verify Patient’s Insurance Covers Telemedicine
While many states have parity laws in place and all states have some version of telemedicine or telehealth covered, there are a multitude of insurance companies and plans inside those companies. The only way to assure that the patient has coverage for Telemedicine, Telehealth, and/or Remote Patient Monitoring services and the out-of-pocket cost of those services to the patient is to verify verbally or electronically with the insurance of the patient. Nothing is worse than getting a bill for something that was thought to be fully or at least partially covered.
There are many opportunities for patients that have no insurance or insurance that will not pay for digital health services to pay a low, flat-fee cash price.
Services such as Wheel or through major medical centers may charge a nominal fee in place of billing an insurance payor. This allows for people to seek the care they need, whether that care is for chronic conditions or acute, and stay healthy in this time of global disease and fear.
CPT Codes For Telemedicine
What Are CPT Codes?
Current Procedural Terminology (CPT) are the billing codes created by the American Medical Association (AMA) that allow for insurance company's reimbursement.
There are not to be confused with the ICD-10 codes that are the diagnosis codes a provider will associate with the CPT codes. CPT codes include the level of service, procedures performed, and vaccines administered during a visit. For obvious reasons, during a digital health service, these CPT codes are a bit more limited than an in-person evaluation would be. Common CPT codes for the telemedical visit would include: codes for service, codes if RPM was completed during the evaluation, and codes for interventions performed (i.e. depression or fall screenings).
What CPT Codes Are Used For Telemedicine
Telemedical visits tend to be billed based upon time spent with the patient on assessment, diagnostics, and counseling.
This is directly opposed to an in-person visit where the billing is based upon systems evaluated during the consultation. It is still possible to build based upon systems evaluated during the visit. However, the limitations associated with completing a physical exam on a telemedical visit decreases this efficacy. Remote patient monitoring such as the utilization of glucometers, digital stethoscopes, blood pressure cuffs, etc to aid in the evaluation and increases the ability to obtain reimbursement. In some states, RPM can be coded and billed for its own reimbursement.
Please see the chart below for codes associated with telemedical billing. The majority of codes will still be the 9920X or 9921X for new and established patients respectively, but as previously mentioned, this is more time based than systems-based. The trickiest part of telemedical billing will come from CMS and their check-in codes and properly spacing them out from in-person visits so as to not lose the reimbursement.
Medicare Telemedicine Billing Codes
No matter what virtual care service or insurance payer is being used, make sure to call beforehand to confirm accurate telemedicine billing guidelines.
Below is a list of recent telemedicine billing codes:
Telehealth consultations, emergency department or initial inpatient
Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs
Office or other outpatient visits
Subsequent hospital care services, with the limitation of 1 telehealth visit every 3 days
Subsequent nursing facility care services, with the limitation of 1 telehealth visit every 30 days
Individual and group kidney disease education services
Individual and group diabetes self-management training services, with a minimum of 1 hour of in-person instruction furnished in the initial year training period to ensure effective injection training
Individual and group health and behavior assessment and intervention
Telehealth Pharmacological Management
Psychiatric diagnostic interview examination
90951, 90952, 90054, 90955, 90957, 90960, 90961
End-State Renal Disease (ESRD)-related services included in the monthly capitation payment
End-State Renal Disease (ESRD)-related services for home dialysis per full month, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents
End-State Renal Disease (ESRD)-related services for home dialysis per full month, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents
End-State Renal Disease (ESRD)-related services for home dialysis per full month, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents
End-State Renal Disease (ESRD)-related services for home dialysis per full month, for patients 20 years of age and older
End-State Renal Disease (ESRD)-related services for dialysis less than a full month of service, per day; for patients younger than 2 years of age
End-State Renal Disease (ESRD)-related services for dialysis less than a full month of service, per day; for patients 2-11 years of age
End-State Renal Disease (ESRD)-related services for dialysis less than a full month of service, per day; for patients 12-19 years of age
End-State Renal Disease (ESRD)-related services for dialysis less than a full month of service, per day; for patients 20 years of age and older
Individual and group medical nutrition therapy
Neurobehavioral status examination
G0436, G0437, 99406, 99407
Smoking cessation services
Alcohol and/or substance (other than tobacco) abuse structured assessment and intervention services
Annual alcohol misuse screening, 15 minutes
Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
Annual depression screening, 15 minutes
High-intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual, includes: education, skills training and guidance on how to change sexual behavior; performed semi-annually, 30 minutes
Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes
Face-to-face behavioral counseling for obesity, 15 minutes
Transitional care management services with moderate medical decision complexity (face-to-face visit within 14 days of discharge)
Transitional care management services with moderate medical decision complexity (face-to-face visit within 7 days of discharge)
Advance Care Planning, 30 minutes
Advance Care Planning, additional 30 minutes
Family psychoanalysis (without the patient present)
Family psychoanalysis (conjoint psychotherapy) (with patient present)
Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour
Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes
Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (list separately in addition to code for inpatient evaluation and management service)
Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (list separately in addition to code for prolonged service)
Annual Wellness Visit includes a personalized prevention plan of service (PPPS) first visit
Chart from eVisit Virtual Care Blog
Telemedicine Billing & CPT Codes For Different Types of Consults
As per the chart above, there are many different codes for telemedical services. These services are usually coded based upon time spent with the patient and medical decision making and medical risk of the provider. However, similar to in-person coding rules, systems evaluated and complexity becomes factors in the coding of visits. Especially with the addition of home digital assessment equipment (i.e.: digital stethoscope, blood pressure and glucometers, pulse oximeters, and many more) the provider can complete almost as full an assessment as they could in the office. The limiting factor does the patient, facility, or office, where the patient is located, have access to this technology.
Telemedical, telehealth, and RPM visits can also be completed for in-patient care both in the acute and sub-acute settings.
Teleneurology and telecardiology are popular uses of telemedical services in the acute care setting. Waiting for a neurologist or cardiologist to come in and assess a patient potentially having a stroke or heart attack in the middle of the night prior to any intervention can be the difference between life and death. This allows the proper specialist to be involved that much quicker and transfer to an appropriate facility to be arranged in a much more efficient and timely manner.
Telephone & Virtual E-Visit Check-ins
E-visits or telephone check-ins are usually audio-only consultations between the provider and the patient. These usually allow just for check-ins to assure that chronic care management (CCM) goals are met and that the patient is remaining safe. Specific requirements for e-visits/telephone check-ins include: not being billed within 24 hours of an in-person visit and cannot be followed by an in-person visit within seven days.
Telephone check-in codes are usually billed as G2010 or G2012. Time-based Telephone codes (audio only encounters) are 99441-99443 depending on how much time is spent with the patient on the phone.
CPT codes 98966 to 98968 are codes that can be utilized by social workers, psychologists, physical and occupational therapists as well as speech and language therapists for billing of their telehealth encounters with the patients.
Remote Patient Monitoring (RPM)
Remote Patient Monitoring (RPM) is an up and coming portion of telemedicine and telehealth. RPM encompasses any and all technology that can monitor a patient in their home or other remote location and transmit this data to their nurse, provider, or other members of the healthcare team.
During the public health emergency of COVID-19, guidelines have been updated, especially with CMS to allow for billing of the RPM services. These services can be billed on a monthly basis. CPT codes of 99091, 99457-99458, 99473-99474, and 99493-99494 are all codes that are reimbursable for the RPM services.
Coding and billing are essential to the maintenance of the healthcare system. Unfortunately, receiving money is a necessity as there is a business aspect to the medical world. We must receive funds to keep our doors open and the lights on. Medical school, nursing school, and the various other training programs do not adequately teach our young and upcoming clinicians how to properly bill, code, and fully understand all private and governmental insurances. This knowledge is usually won over years of practice.
Early 2020 with the onset of coronavirus obscured the clinical picture for many people and brought the world of telemedicine to the mainstream.
With this change in the type of service being sought, medical care, billing, and coding were forced to make changes and reimbursement policies were modified.
How long COVID-19 will be around and continue to affect our society is yet to be seen. What changes to billing, coding, and all practice applications that occurred during the beginning to middle of 2020 have no end in sight. It is impossible to predict what rules and regulations will continue as they are or go back to the way they were or to a completely different model.
Medical Practitioners, billing, and coding team members, and practice administrators must remain vigilant about the intricacies of these rules and regulations. This ensures that providers and practices will be compensated for their efforts and the patients utilizing these services will be able to afford them.