Pediatric Coding Alert

Question: We would like to start using telehealth in our pediatric practice — we think it would be perfect for our college-age patients, especially for checking their meds and prescribing refills. We know that we can only use the synchronous services listed in CPT^® Appendix P and that we need to append modifier 95 and POS 02. What else do we need to know before going ahead with this?

Codify Subscriber

Answer: While you have the basic coding aspects of telehealth correct, you’ll need to make sure you know your payers’ guidelines before you proceed with this service for your long-distance patients. Telehealth services consist of more than communicating with your patients “using interactive telecommunications equipment that includes, at a minimum, audio and video,” selecting the appropriate, CPT^®-approved services from the Appendix P codes and appending modifier 95 (Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system) and place of service (POS) code 02 (Telehealth) to your claim per CPT^® guidelines.

If you are billing Medicare or a payer that follows Medicare guidelines, you may encounter a problem with the originating site — the place where your patient will need to be for the service to be eligible. The Centers for Medicare and Medicaid Services (CMS) requires these sites to be in either:

• A county outside of a Metropolitan Statistical Area (MSA) or
• A rural Health Professional Shortage Area (HPSA) located in a rural census tract.

Additionally, while Medicare and payers following their guidelines have no problem with a provider being “in a distant, or remote, site” of their choosing, the patient’s originating 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 according to CMS guidelines (Source: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf). In the scenario you describe, however, this should not be a problem, as a campus health center should qualify as an originating site providing it is equipped with audio and video equipment.

There is some good news for your project, though. More and more private payers are breaking away from Medicare rules to provide broader coverage for telemedicine. So, it would be a good idea to contact any private insurances you deal with to find out which services they cover and whether there are any restrictions or conditions place on that coverage, such as how many telemedicine visits you can bill per year and which of your providers are eligible to bill for them.