Medicare Compliance & Reimbursement

Tip: Understand the basics of the 4 virtual service options.

Remember: Over the last few weeks, the Centers for Medicare & Medicaid Services (CMS) has issued a series of press releases and fact sheets (March 17 and March 30) in addition to an interim final rule published in the April 6 Federal Register to address the rapid spread of the COVID-19 virus. Many of the coverage and coding updates promote “flattening the curve” of the pandemic with telehealth expansions that safeguard vulnerable beneficiaries and boost providers’ care options (see Medicare Compliance & Reimbursement, Vol. 46, No. 6 and No. 7).

“These changes allow seniors to communicate with their doctors without having to travel to a healthcare facility so that they can limit risk of exposure and spread of this virus,” explains CMS Administrator Seema Verma. “Clinicians on the frontlines will now have greater flexibility to safely treat our beneficiaries,” Verma adds.

Read on for a review of four virtual service options available during this public health emergency (PHE).

Distinguish Between the Various Digital Offerings

First, you must differentiate between a Medicare telehealth visit and a virtual check-in. A virtual check-in involves a “brief” communication between patient and provider, typically from the confines of the patient’s own home. However, the type of communication modality for a virtual check-in does not involve face-to-face (F2F) interaction. Rather, patients will bypass the audiovisual means of communication for an audio-only exchange with the provider. This form of service qualifies as telemedicine.

According to CMS, virtual check-ins are designated for new and established patients of physicians or eligible 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 March 17 fact sheet indicates.

For your typical Part B telephone-based virtual check-in that lasts under 10 minutes, you’ll report HCPCS code G2012 (Brief communication technology-based service, e.g. virtual check-in … 5-10 minutes of medical discussion). While the guidelines are shifting during this fluid situation, most commercial payers require that you report the following code set for virtual check-in services:

• 99441 (Telephone evaluation and management service by a physician… 5-10 minutes of medical discussion)
• 99442 (…11-20 minutes of medical discussion)
• 99443 (…21-30 minutes of medical discussion)

For qualified non-physician healthcare professionals (QNHPs) who cannot perform and bill for E/M services, you’ll report code range 98966-98968 for telephone-based services.

Billing update: In the interim final rule, CMS indicates that it will reimburse for 99441-99443 during the extent of the COVID-19 PHE. Additionally, both new and established patients qualify for 99441-99443 reporting to both CMS and commercial payers. This means that for Medicare virtual check-ins that extend beyond the 10-minute mark, you should report code range 99442-99443, depending on time spent communicating with patients. Lastly, keep a look out for information on Medicare retroactive billing for code range 99441-99443 that will apply from a specific date in March.

Important: Reserve HCPCS code G2010 (Remote evaluation of recorded video and/or images…) for “store and forward” services in which a patient sends a practitioner an image or video and the practitioner responds within 24 hours.

Code E-Visits for Patient Portal Communication

The third type of virtual service you’ll want to consider is an e-visit. On the surface, these services may look similar to virtual check-ins. However, the difference lies with the channel of communication. “E-visits (digital communication) take place through a secure online portal,” relays Natalie Ruggieri-Buzzelli, CPC, CGSC, HIM coding specialist at the Hospital of the University of Pennsylvania.

“E-visits are a patient-initiated encounter between a physician or other qualified healthcare professional. If the inquiry is related to a surgical procedure within a global period, then the service is not reported. The provider must keep a permanent record on file. Other rules apply and are listed in the CPT^® manual,” outlines Ruggieri-Buzzelli.

E-visits are exclusive to established patients and may include time spent for interaction for up to seven days. This means that providers must document the time associated with each interchange in order to add up the time spent at the end of the seven-day period. E-visits may be performed by physicians or advanced practice providers (APPs) using one of the following three time-based E/M 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 (…11-20 minutes)
• 99423 (… 21 or more minutes)

Reminder: The fourth type of virtual care involves remote monitoring via code range 99453-+99458, in addition to code 99091 (Collection and interpretation of physiologic data…requiring a minimum of 30 minutes of time, each 30 days). This can include remote heart monitoring, blood pressure monitoring, blood sugar monitoring, etc. These services not only provide extensive data to the provider, but also ongoing feedback to the patient.

Boost Your Modifier IQ With These Guidelines

There are four modifiers you’ll want to consider for telehealth (audiovisual) code reporting:

• 95 (Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system)
• GQ (Via asynchronous telecommunications system)
• GT (Via interactive audio and video telecommunication systems)
• G0 (Telehealth services for diagnosis, evaluation, or treatment, of symptoms of an acute stroke)

Medicare Part B requires the use of modifier 95 on telehealth claims during the extent of the PHE. Some commercial payer policies also require that you append modifier 95 to telehealth claims. You should check on individual payer guidelines prior to reporting modifier 95 with your claims for non-Medicare Part B payers.

The remaining three modifiers are based on circumstantial and/or location considerations.

You should only report modifier GQ when the telehealth service is furnished “via asynchronous (store and forward) technology as part of a federal telemedicine demonstration project in Alaska and Hawaii,” CMS maintains. Furthermore, modifier GT is designated for billing under Critical Access Hospital (CAH) Method II while modifier G0 may be used universally among providers and locations so long as the criteria for the modifier has been met.

Collect the Correct POS Details to Avoid Coding Conundrums

The place of service (POS) code that you use for telehealth claims should represent the place where the service would have been traditionally provided had it been a F2F visit. That’s because all telehealth services provided during the PHE are considered “nontraditional” telehealth services.

With a traditional telehealth service, Medicare pays the “originating site” the facility fee, leaving the provider with a reduced fee that takes out the overhead paid to the originating site. Since providers are still incurring overhead and there is no facility fee paid to an originating site, CMS has determined that the reduction in the fee schedule is not justified. This means that an office visit performed over telehealth under the PHE would be billed with a 95 modifier and POS of 11 (Office) for the office, even though the provider and patient may be communicating from their respective homes.

Auxiliary Agencies Receive Telehealth Funds for Providers

If your practice is struggling to get telehealth up and running, you may want to look into these two programs funded by the Coronavirus Aid, Relief, and Economic Security (CARES) Act.

1. Federal Communication Commission (FCC): As part of the CARES Act, the FCC was allocated $200 million for its COVID-19 Telehealth Program. The commission aims to help “eligible” healthcare providers connect with patients with funding for “telecommunications services, information services, and devices,” the FCC says.

“Only nonprofit and public eligible healthcare providers that fall within the categories of healthcare providers in section 254(h)(7)(B) of the 1996 Act” can apply for the funding, according to an FAQ. The FCC lists the following eligible providers: teaching hospitals; community health centers; local health departments; community mental health centers; not-for-profit hospitals; rural health clinics; skilled nursing facilities; or a consortium of one or more of the provider types listed already.

If interested, FCC urges eligible providers to apply ASAP before funding expires or the COVID-19 pandemic ends. Find out more and apply at www.fcc.gov/covid-19-telehealth-program-frequently-asked-questions-faqs.

2. Health Resources and Services Administration (HRSA): Congress appropriated $180 million to HRSA for telehealth activities and rural health assistance under the CARES Act provisions. Among its programs, HRSA offers providers two options: the Telehealth Focused Rural Health Research Center Program and the Telehealth Network Grant Program.

Find out more about the two these two options, including grants, and eligibility at www.hrsa.gov/rural-health/coronavirus-frequently-asked-questions#telehealth.