Telemedicine and telehealth are two terms that people often use interchangeably. Telehealth is more concerned with the exchange of medical data from one source to the other through some form of electronic communication interface.
On the other hand, telemedicine is more related to providing the practice of medicine remotely with the help of technology.
These are somewhat similar, yet some people believe that each practice carters to a specific type of service. This is not the case, as both of these terms are broad and encompass different types of services.
Types of Digital Services
There are three types of digital or virtual services. Physicians and other healthcare providers offer Medicare patients and beneficiaries any of the three services.
These services include Medicare telemedicine visits, E-visits, and virtual checkups. Each of them encompass different definitions and complies with different CPT codes. They also carry a varied patient relationship with the provider.
Related: Complete guide on starting a telemedicine business
Billing and Documenting Telemedicine Codes
The year 2020 presented one of the unprecedented times that people had ever witnessed. One of the very interesting healthcare innovations that came out of this time was the introduction of telehealth codes. In the midst of the covid-19 uncertainties, people had to scramble in chaos when it came to receiving healthcare.
Your board and payers are the ones that will give you the most important rules that apply specifically to you and your situation. The telemedicine codes are not new, and they have existed for a long time.
The first set of codes includes the telephonic codes. They dictate what you can do and your billing process when interacting with the patient over the phone. Some medical coverage will not include this set of codes. This does not mean that they do not apply to the fee schedule. Instead, these codes fall into the evaluation and management family of codes.
Healthcare professionals will often provide their contact numbers to patients. This allows the patients to reach out to the doctor for general queries. However, if there needs to be a true consultation over the phone, the healthcare provider can charge the patient for the remote interaction.
This is where CPT codes come in, and they dictate a system of charging the patients for telemedicine practice according to different factors. The telephonic codes are divided by the duration. Healthcare professionals must document the telephonic conversation and its medical necessity in this instance.
Online Digital Health Codes
The second set of codes is for the online digital telemedicine services. This is what took over the healthcare industry during the coronavirus pandemic. It involves the online platforms that enable physicians and patients to video conference and monitor vitals. These codes are also divided by timeframes, and they require an online, two-way visual conversation.
Related: How to develop a telemedicine application
Rules on Billing and Telemedicine Codes
With the onset of digital healthcare and its incredible prospect for the future, patients and physicians need to be aware of them. It would help if you remembered that while some of these rules may be covered while others may not be. Healthcare practices need to find out about this from the payers individually.
Some payers clarified what you can and cannot do. Billing codes is a subject that can be confusing for practitioners. It is very important to understand what your allowances are from your board, along with your coverage.
You should also be considerate of the HIPAA requirements. They relaxed the rules on the security of information during crises. This is because people often have to reach doctors in the state of an emergency. You cannot tell whether the board decision-makers at HIPAA will intervene in the future.
This is why healthcare workers need to stay on top of the legislation. You may have to store and record patient data if you have coverage. But, make sure that you are not violating any rights to the privacy rule. To ensure that you are complying, you have to keep your HIPAA updated.
A breach could be devastating for a healthcare professional’s practice. It can lead to you losing your license. This is also a reason to ensure you always check Medical Review Policy.
Every payer has put out a medical review policy for telehealth and telemedicine. Overall, the steps to keep your telemedicine practice safe will involve checking with your payer and making sure that your HIPAA is updated.
Coding And Modifiers For Telehealth Services
- 95 – If you are going to bill for telehealth more often, you have to get used to the 95 modifiers. This modifier refers to asynchronous telemedicine service rendered by an interactive video or audio communication system in real-time.
- CR – This modifier pertains to the service you have rendered related to a catastrophe or disaster. You can apply this modifier for emergencies.
- GQ – You can apply this modifier via asynchronous communication. Some plans want you to build this while others do not require it. This modifier was around even before the coronavirus outbreak. This is part of a federal telemedicine project.
- GT – This modifier applies to an interactive video and audio telecommunication system. You have to bill this code under the CAH Method 2. The CAH method is short for critical access hospitals. Some payers will reimburse based on appendix-P. However, appendix P is very rare.
Box 24B: Place of Service Codes
There are about 70 different places of service codes. Most healthcare providers are used to one of them, which is the number 11. This number refers to the office, while the number 2 means telehealth, and the number 12 means home.
For clients that go to the patient’s place of employment, the number is 18. There are also place-of-service codes for hospitals, nursing homes, and assisted living facilities. Similarly, you also have the telehealth site locations.
If you are going to provide telehealth, you will have to document the site locations so you do not forget about them. The site location includes the “originating site” and the “distant”. The originating site declares the patient’s location, and the “distant” code refers to where the healthcare provider is present at the time.
Billing managers should be aware that the originating site location will not include the home. The home is not normally considered an original location, but it is now included in the originating location due to the coronavirus pandemic. The 1135 waiver covers this part of the change.
New Diagnosis Codes
For nurse practitioners offering telemedicine services, it is important to note that there are new diagnosis codes. These codes are related to the covid-19 virus, and they represent respiratory infections, upper respiratory infections, pneumonia, coughs (r05), and shortness of breath (r0602), unspecified fever (r50.9).
As a nurse practitioner, you will have to update your diagnosis codes since you will most likely deal with this. These codes can also be subject to further updates and replacement. This is why you have to stay on top of all the regulatory changes.
How to Bill for Telemedicine Visit?
Understanding the nuances of billing and coding for telemedicine can be difficult, especially considering their changes. These changes were a response to the public health emergency. Payers, including CMS and private payers, have significantly expanded their telehealth availability regarding coverage and payment.
This helps increase patients’ access to healthcare providers in times of uncertainty. The telemedicine codes allow patients to receive care remotely and get reimbursed appropriately. For some practitioners, billing a code can be very confusing. Understanding the best ways to bill for the services they provide will optimize reimbursement and allow them to continue practice operations.
Mentioned below, is a list of codes that can allow you to bill for some of the common telehealth services during the covid19 pandemic.
CPT: G2012 (5 – 10 mins)
This is a virtual check-in code. A virtual check-in code is designed to be a 5 to 10-minute phone call or video chat. This phone call or video interaction helps a patient determine the issue they are currently experiencing and whether it warrants a more extensive visit via in-person or telemedicine.
This is not meant to be an extensive evaluation, and you can also perform it with the help of a staff member and not necessarily with a provider. When using this code in the billing process, you can use your usual place of service. For a regular clinic, the place of service would be 11, and you would not need to apply any modifiers.
CPT Code: G2010
This next new code that has become available to allergists during the coronavirus pandemic involves remote review of images and video. An example of this is a patient sending an image through the patient portal to review and give opinions. For outpatient clinics, the place of service will be 11, and you will not have to use any modifier.
Telephone care is a service that most often goes uncompensated. Many doctors have previously provided free over-the-phone care to their patients. Nonetheless, during public health emergencies, payers have recognized that telephone care is much significant for some patients. These patients do not have video conference availability.
Therefore, the codes already established for telephone care are being reimbursed. Below is a list of codes that healthcare professionals can use for billing telephone visits.
- 99441 (5-10 minutes)
- 99442 (11-20 minutes)
- 99443 (21-20 minutes)
The place of service will depend on where you are practicing from, and the modifiers are typically not necessary. Next, you have synchronous face-to-face video visits. In other words, the telemedicine visits. These codes are billed using the standard codes that a healthcare provider normally uses for patient care.
Previously, it has been very difficult to get telemedicine coverage delivered to new patients. This is because many states and payers have requirements. These requirements need individuals to establish patients of the specific practice. Moreover, states require a physical exam on file before a healthcare professional or billing manager could bill for telemedicine services.
During the public health emergency, this has been waived, and you now have the opportunity to provide your new patient’s telemedicine care easily. You can do this by using your standard codes, which are 99201, 99202, 99203, 99204, and 99205. You can bill them using a time-based approach or medical-decision billing approach.
For established patients, the rules will apply the same way. The codes are 99211, 99212, 99213, 99214, and 99215. This applies to either time-based billing or medical decision-making.
Historically, the place of service designated for telemedicine is 02, which designates telemedicine visits. However, many payers have reimbursed telemedicine care at a lower rate than live visits.
To simplify coding and billing processes, the guidance for most pairs has been to use the usual place of service to guarantee payment parity and optimize your reimbursement. Therefore, while using a place of service 11, you would then use a modifier 95 or GT to designate the telehealth services.
This is not a uniform recommendation amongst all payers. TRICARE and Aetna, along with a number of state medicare plans still give the guidance to use 02 as the place of service. The best way to find out how to bill would be to reach out to your payer for advice.
A new code that people can use during the public health evaluation for most payers includes the digital health evaluation code. You can also refer to this code as the E-visit code.
You would use this code when a patient reaches out to you for medical guidance via a secure electronic guidance portal such as the HIPAA compliance portal. Generally, this code would only apply if the patient initiates the visit.
An interesting thing about billing for digital health evaluation or E-visit codes is that they are accumulative time-based systems that run over seven days.
Healthcare professionals have to add up the time they spent reviewing, responding, and researching for a single patient for seven days. Once they review the time, they can add it all up and bill for the accumulative amount of time.
The codes for digital evaluation are:
- 99421 ( 5-10 minutes)
- 99422 (11-20 minutes)
- 99423 ( greater than or equal to 20 minutes)
COVID-19 Regulatory Changes and Updates
Several changes took place regarding telehealth services. On March 17th CMS issued guidance towards the Secretary Azar’s Waiver Authority. This broadens the access to Medicare services for telehealth. Although telemedicine services are not new, CMS announced waivers for them because more and more people are now using them.
Typically, when you bill telemedicine services to medicare, they only pay for certain services. It’s also worth keeping in mind that there are about 101 CPT codes that qualify for telemedicine, according to medicare.
This has broadened immensely during the public health emergency. You can now find several different codes that are eligible. You also no longer have to use the modifier GT and as you can use the modifier 95 instead. This is the modifier that most commercial insurance use to indicate when billing for a telemedicine service and not a physical practice.
When you bill these services to medicare, they only pay for certain specific ones. You will have to bill with the modifier GT, indicating that the service was telemedicine. There are about 101 CPT codes that qualify for telemedicine practices. These services must be patient-initiated, which means that physicians will only apply them if a patient reaches out to the doctor and not the other way around.
Geographical Restrictions waived
There are many restrictions that the federal authorities have waived to make telemedicine health services more widely available. Telehealth services were not popular before the pandemic because you could not perform the service for any patient in any area of the country. Instead, there were particular locations.
To bill for telemedicine services, patients had to be in a rural area where they did not have easy access to medical facilities or a healthcare provider. Therefore, Medicare would cover them for their digital checkups and monitoring.
As the public health emergency came about and authorities started mandating social distancing policies to reduce exposure and spread of the virus, the decision-makers lifted this waiver. This allows any physician to perform and bill for digital healthcare service regardless of the patient’s location.
Originating Location Requirement Waived
Another element of the billing restrictions was that the patient could not be in the comfort of their home. They instead had to travel to a nearby hospital or clinic that had types of equipment set up for them to perform audio and visual interactions. This qualified as an originating site in the modifiers.
However, since the covid19 pandemic encouraged every patient to stay within their premises, this restriction has also been waived. A patient’s home now qualifies as an originating site as well.
It is important to realize that much of the telehealth expansion is temporary. This is not to say that telehealth expansion and payers are not currently in place. These expansions and new billing updates are likely to extend and change in response to the CMS recommendations.