Pediatric Coding Alert

Learn the Difference Between Telemedicine and Telehealth

First, some definitions to make sure you can keep everything straight.

Telemedicine is the practice of medicine using technology to deliver care at a distance. It occurs using telecommunications between a patient (at an originating site) and a physician or other practitioner licensed to practice medicine (at a distant hub or site).

Telehealth is the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision, and information across distances. It seeks to improve a patient’s health by permitting two-way, real-time interactive communication between the patient and the physician or practitioner at a distant site.

A distant site is a secure site or location where a healthcare provider is located while providing services via a telecommunications system, while an originating site is where the patient is located at the time the services are delivered. Importantly, “you can’t charge for the originating site when the patient is home because you aren’t using your office for the patient. Remember that when you are billing,” warned Wilson.

See What Changed After PHE

After the PHE officially ended on May 11, 2023, the Consolidated Appropriations Act of 2023:

• Extended the availability of telehealth services that can be furnished using audio-only technology through December 31, 2024.
• Continued allowing Medicare beneficiaries to access telehealth services in any geographic area in the United States rather than only in rural areas. (Be aware that this may differ for non-behavioral or mental telehealth services).
• Continued to allow all providers who are eligible to bill Medicare for professional services to provide distant site telehealth services.
• Continued to allow people with Medicare to stay in their homes for telehealth visits that Medicare pays for rather than having to travel.
• Expanded the list of eligible providers.

Allowed Medicare to pay for phone evaluation and management (E/M) visits at the same rate as payment for office/outpatient visits with established patients. “Medicare saw providers were spending a lot of time performing telehealth visits, so they began paying at the same rate as an OP visit,” said Wilson.

Allowed Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to provide telehealth services to Medicare beneficiaries.

Take note: This is not an all-inclusive list, so please be sure to check your local information before billing telehealth services.

Under these new rules, you should “remember that if a visit is audio-only, be sure you are noting that in the medical record,” she added. If you do code for audio-only services, be sure to add the appropriate modifier FQ (The service was furnished using audio-only communication technology) or FR (The supervising practitioner was present through two-way, audio/ video communication technology) to the claim. “FQ can be used with two exceptions: the beneficiary is incapable of two-way audio/video technology, or the beneficiary does not consent to the use of two-way audio/video technology,” said Wilson. Note that CMS introduced these modifiers specifically for use with mental health services.

Remember: Audio only calls are coded using 99441 (Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion), 99442 (…11-20 minutes of medical discussion), and 99443 (21-30 minutes of medical discussion). “Keep in mind that these codes are set to be deleted January 1, 2025, so it will be interesting to see how these are updated going forward,” Wilson said.

Bill For Online Digital Visits

For online digital E/M video visits, for established patients, for up to 7 days (cumulative time during the 7 days), you will look to 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), and 99423 (…21 or more minutes).

When you bill these codes, make sure the physician documents the following:

• Proof the encounter was not initiated by the doctor
• Patient location
• Chief complaint/reason for encounter
• Justification for services
• Pertinent history and exam
• Medical decision making
• Applicable diagnoses
• Duration of encounter

Remember: You will also need to document that the service did not lead to a related, separately reported E/M service within seven days of the initial online digital service. If that happens, you must bundle the work involved in 99421 into the more comprehensive E/M service, and bill only that code.

Understand Changes in Supervision Requirements

The Centers for Medicare and Medicaid Services (CMS) temporarily modified the regulatory definition of direct supervision, which requires the supervising physician or practitioner to be “immediately available” to furnish assistance and direction during the service, to include “virtual presence” of the supervising clinician using real time audio and video until Dec. 31, 2024.

“Post PHE, Continuing Medical Education (CME) allows teaching physicians in all teaching settings to be present virtually through audio/video real-time communications technology for purposes of billing under the Medicare Physician Fee Schedule (PFS) for services they furnish involving resident physicians,” said Wilson. CMS will also change or update this policy on Dec. 31, 2024.

Use These Modifiers

You should include the modifiers below should be included on telehealth service claims as appropriate:

• Modifier 95 (Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System). This modifier is required on telehealth services when the practitioner is in a facility setting and the patient is in their home during the visit.
• Modifier 93 (…rendered via telephone or other real-time interactive audio-only telecommunications system).
• Modifier FQ
• Modifier FR

Note: Modifier CS (Cost-sharing waived for specified covid-19 testing-related services that result in and order for or administration of a covid-19 test and/or used for cost-sharing waived preventive services furnished via telehealth in rural health clinics and federally qualified health centers during the covid-19 public health emergency) is no longer valid on claims post-PHE from May 11, 2023, and beyond.

Lindsey Bush, BA, MA, CPC, Development Editor, AAPC