Primary Care Coding Alert

Let this primer get you up to speed.

With its ever-changing codes and complex guidelines, the brave new world of telehealth is a tough place for coders. Even knowing the difference between telehealth (defined as any health service provided by telecommunications) and telemedicine (defined as any clinical service provided by telecommunications) can be a source of coding confusion.

So, we thought this would be a good time to see what’s changed and what’s stayed the same by looking at the four key areas you should track to stay ahead of the telehealth game.

1. Keep Up With Telemedicine Code and Modifier Changes

“One of the greatest challenges facing telemedicine coding is that changes in technology typically occur faster than changes in coding,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

“CPT^® code change proposals are often generated and acted upon more than a year before the changes/new codes appear in CPT^®, and CPT^® itself is only published once a year. So, it’s easy to see how technology moves faster, leaving coders to wonder if a new telemedicine service fits an existing code or needs to be reported using an unlisted code,” Moore adds.

As an example of this rapid change, the Centers for Medicare and Medicaid Services (CMS) introduced two new HCPCS codes for 2019: G2012 (Brief communication technology-based service, e.g. virtual check-in...) and G2010 (Remote evaluation of recorded video and/or images submitted by an established patient...), which you can use when your provider is evaluating information to determine if a patient needs to be seen in the office.

In addition, CMS added two prolonged service codes, G0513 (Prolonged preventive service(s) … first 30 minutes ...) and G0514 (… each additional 30 minutes ....) to the telehealth service list. CMS also revised its regulations to expand access through telehealth for patients with end-stage renal disease (ESRD) receiving home dialysis and acute stroke patients.

One way to stay current with telemedicine codes is to consult Appendix P in your CPT^® manual. Documenting any service listed there when provided via telemedicine is as easy as appending modifier 95 (Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system). You will also need to add a place of service (POS) code 02 (Telehealth) to your claim to indicate that your provider is at the distant site (as opposed to the originating site where the patient is located).

GT No Longer Needed: As of January 1, 2018, unless you are billing claims from a critical access hospital (CAH) under method II for institutional claims, you will no longer need to apply modifier GT (Via interactive audio and video telecommunication systems) to a Medicare telehealth claim. But modifier GQ (Via asynchronous telecommunications system) is still required for asynchronous communication when appropriate, Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania, reminds coders.

2. Understand What Isn’t Telemedicine

While telemedicine can involve the use of telephone communication, two groups of telephone evaluation and management (E/M) codes are not regarded as telemedicine.

Codes 99441 through 99443 (Telephone evaluation and management service by a physician or other qualified health care professional … provided to an established patient, parent, or guardian …) and 98966 through 98968 (Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian …) are not regarded as telemedicine because CPT^® does not regard them as being “face-to-face” services.

The same is true for 99444 (Online evaluation and management service provided by a physician or other qualified health care professional … using the Internet or similar electronic communications network), which is also regarded as non-face-to-face and would also not be defined as telemedicine by virtue of its asynchronous nature.

3. Get to Know Location for Medicare Coverage

“Medicare rules surrounding billing telehealth services can also be confusing,” says Moore. “For those services that are on the telehealth list —services typically provided in-person, but which CMS has agreed to pay if provided using two-way audio and video real-time technology — there are restrictions on where the patient can be and what can serve as an originating site,” Moore cautions.

For example, Medicare will only reimburse for beneficiaries if they 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.” However, some private payers, such as United Healthcare, have no such policy.

Additionally, while there is 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 Centers for Medicare and Medicaid Services (CMS) guidelines (Source: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf). Again, some private payers are not so restrictive about this.

4. Know That Private Payers Are Increasing Coverage

“Private payers are also rapidly moving ahead of Medicare to provide much broader coverage, even though they each do things a little differently,” says Falbo. As of last year, 35 states have passed parity laws for telemedicine, meaning that payers are required to pay the same rates for comparable in-person and telemedicine services, while four more states have parity bills on the table according to the American Telemedicine Association (Source: www.americantelemed.org/main/policy-page/state-policy-resource-center#.VbKBG7NVikp).

To find out a private payer’s guidelines, Falbo suggests you should ask the following four questions:

• Which telemedicine services do you cover?
• What kinds of providers are eligible to bill for these services?
• How many telemedicine visits do you cover per year?
• What restrictions and conditions apply to telemedicine visits?

The answers you get will help keep you ahead of the telemedicine learning curve.