Pediatric Coding Alert

Dial-in Your Knowledge of Telehealth Services

Master check-in, e-visit, and telemedicine coding with this guide.

The current COVID-19 public health emergency (PHE) has created a host of questions and misunderstandings about telehealth coding.

Here is a comprehensive guide to the different types of telehealth services and their related guidelines. The Centers for Medicare & Medicaid Services [CMS] have waived many of them during the healthcare emergency, as the previous article notes, and it is unclear at the time of writing which, or how many, of the guidelines will be restored when the emergency is over.

Virtual Check-In

These are brief communications between a patient and a provider to determine whether a patient’s condition requires further services.

Which codes do I use?

Use 99441 (Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services …; 5-10 minutes of medical discussion), 99442 (… 11-20 minutes of medical discussion), or 99443 (… 21-30 minutes of medical discussion) for telephone communications with physicians or other qualified healthcare professionals.

Use 98966 (Telephone assessment and management service provided by a qualified nonphysician health care professional …; 5-10 minutes of medical discussion), 98967 (… 11-20 minutes of medical discussion) or 98968 (… 21-30 minutes of medical discussion) for telephone communications with qualified nonphysician healthcare professionals (QNHPs) such as physical or occupational therapists, clinical psychologists, or speech language pathologists who cannot perform and bill for evaluation and management (E/M) services.

Use G2012 (Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional …; 5-10 minutes of medical discussion) for real-time, synchronous telephone interactions with Medicaid patients.

Use 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 …) if the patient has sent video, images, or other kinds of data transmissions (such as information from a monitor) for your provider to evaluate.

What are the non PHE limitations on the service?

• Only established patients may receive these services.
• Services must be initiated by the patient.
• Services must not originate “from a related E/M service provided within the previous 7 days” or “lead to an E/M service or procedure within the next 24 hours or soonest available appointment” per the code descriptors.

Coding alert: “The G-code services are not subject to the telehealth service restrictions noted below because the service is performed virtually,” according to Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

E-Visit

These services describe communications through electronic health record (EHR) portals, secure email, or other digital applications.

How do I code the service?

Use 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), or 99423 (… 21 or more minutes) for providers who can perform and bill for E/M services.

Use G2061 (Qualified nonphysician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 5–10 minutes), G2062 (… 11–20 minutes), or G2063 (… 21 or more minutes) according to time for QNHPs who cannot perform and bill for E/M services.

What are the non PHE limitations on the service?

• Only established patients may receive these services.
• Services must be initiated by the patient.
• Services must not originate “from a related E/M service provided within the previous 7 days” per code descriptors.

Telemedicine Visits

These are “services that are typically provided in-person but which CMS has agreed to pay if provided using two-way audio and video real-time technology,” says Moore.

They include face-to-face services such as 99201-99215 (Office or other outpatient visit …), +99354-+99355 (Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service …in the office or other outpatient setting …), and 99495-99496 (Transitional care management services …) that are listed in the pre PHE zip file found at www.cms.gov/Medicare/Medicare- General-Information/Telehealth/Telehealth-Codes. Payers using CPT^® codes will recognize the codes found in Appendix P of the CPT^® manual.

What are the non PHE limitations on the service? Medicare restricts telemedicine services in these ways:

• Communications must use an interactive telecommunications system that consists “at a minimum … audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner.” This does not include telephones.
• Beneficiaries must present in an originating site in “a county outside of a Metropolitan Statistical Area [MSA] or a rural Health Professional Shortage Area [HPSA] located in a rural census tract.” The site is limited to a physician’s office, a hospital, a critical access hospital (CAH), a hospital- or CAH-based renal dialysis center or satellite, a rural health clinic, a federally qualified health center, a skilled nursing facility, or a community mental health center.

Exception (1): Patients with a substance abuse or co-occurring mental health disorder diagnosis can receive treatment from any originating site, including the patient’s home, other than a renal dialysis facility.

Exception (2): Beneficiaries enrolled in Medicare Advantage can receive telehealth services from their homes instead of having to go to one of the originating sites listed above.

• “Transmitting medical information to a physician or practitioner who reviews it later is permitted only in Alaska or Hawaii Federal telemedicine demonstration programs” (Source: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNProducts/downloads/TelehealthSrvcsfctsht.pdf

What about private payers? “Such restrictions vary by payer. Most private payers do not follow the Medicare guidelines and instead use their own guidelines for coverage and payment of telehealth services,” Moore reminds coders.

Modifier alert: CMS formerly requires POS 02 (Telehealth) and no modifier, while some commercial payers want you to use POS 11 (Office) if that is where your provider provided the service. Per CMS telehealth guidelines during the PHE, however, you would use modifier 95 (Synchronous telemedicine service …) along with the appropriate place of service (POS) code to reflect where the service would have been provided if done in-person.

In addition, depending on the way the service was furnished, you would append modifier GQ (Via asynchronous telecommunications system) for services provided by store-and-forward technology. You no longer need Modifier GT (Via interactive audio and video telecommunication systems), except for claims billed by critical access hospitals, or CAHs. As with any coding issue, however, check with your payer for their preference.