Telemedicine for Medicare Patients FAQ

The relatively rapid expansion of remotely provided clinical services from non-reimbursed items to more mainstream (and even reimbursed) services, has resulted in some current definition inconsistencies among different coding/payer methodologies (and sometimes even within a single payer). The following definitions rely heavily on Medicare's policies/procedures. Private payers may have different codes, definitions and requirements for reporting these services.

Telehealth (or Telemonitoring) is “the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distance.”  Telehealth is a broad term and can refer to clinical and non-clinical services involving medical education, administration, and research.  Telehealth includes technologies such as telephones, facsimile machines, electronic mail systems, and remote patient monitoring devices which are used to collect and transmit data for monitoring and interpretation.  For example, physicians use email to communicate with patients, order drug prescriptions and provide other health services.

Telemedicine is more narrowly defined.  Per CMS, “Telemedicine seeks to improve a patient’s health by permitting two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site.  This electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment.”  This is referred to as an “Interactive” system.

Some technologies used in the broader category of telehealth do not meet the definition of telemedicine. These are referred to as “asynchronous, or store and forward, applications”, and include the use of a camera (e.g., audio clips, video clips, still images) to record (store) an image that is transmitted (forwarded) to another site for review at a later time.  Per CMS guidelines, asynchronous technology is permitted only in federal telehealth demonstrations programs conducted in Alaska or Hawaii.

Teleconsultations is another broad term that includes using telecommunications between a patient and a health professional for use in rendering a diagnosis and treatment plan. Generally, in order to bill Medicare, the service provided should meet the definition of telemedicine.

Yes.  CMS requires the reported telemedicine services include both an originating site and a distant site. The originating site is the location of the patient at the time the service is being furnished.  The distant site is the site where the physician or other licensed practitioner delivering the service is located.

A telehealth facility fee is paid to the originating site.  Claims for the facility fee should be submitted using HCPCS code Q3014:  "Telehealth originating site facility fee."  Originating sites include: the office of a physician or practitioner, Hospitals, Critical Access Hospitals (CAH), Rural Health Clinics (RHC), Federally Qualified Health Centers (FQHC), Hospital-based or CAH-based Renal Dialysis Centers (including satellites), Skilled Nursing Facilities (SNF), and Community Mental Health Centers.

Until 2014, only originating sites in low population density rural counties were eligible for telehealth reimbursement.  As of January 1, 2014, originating sites in rural portions of urban and high population counties may also be eligible for reimbursement.  Below is the link for a telehealth calculator to determine if your originating site is eligible for Medicare payment.

http://datawarehouse.hrsa.gov/telehealthAdvisor/telehealthEligibility.aspx

In addition to being able to utilize Office or other outpatient codes (99201-99205) and subsequent hospital codes (99231-99233), the 2020 Medicare (HCPCS) telehealth descriptor codes and RVUs are listed below:

Code, 99490 is for chronic care management and remote monitoring of chronic conditions.

More important, CMS added the following list of services to the Medicare telehealth list on a Category I basis to facilitate correct coding for changes brought about by COVID. They are:

Medicare also created a third temporary category of criteria for adding services to the list of Medicare telehealth services for the COVID public health emergency.  These are services added to the list that will currently remain on the list through the calendar year in which the PHE ends.  Category 3 Services include:

During the COVID-19 pandemic CMS has granted an 1135 waiver allowing the ED E/M codes (99281-99285) to be furnished via telehealth, meaning real time two-way audio and visual interaction. The place of service (POS) code used on the claim should be the same as if the service were rendered face-to face; for the ED that would be POS 23. Include modifier 95 to each claim.   This is true even if the patient is not physically in the ED such as in a remote location or even the patient home.  It is also allowed that the emergency physician may be in a different location even at home.  These waivers are retroactive to services provided after March 6, 2020. CMS also added the telephone services codes (99441- 99443) to the telehealth waiver list and increased the payment for those codes to match the office or other outpatient code values.

Other new relevant additions to telemedicine-covered codes include the ability to utilize more psychoanalysis and evaluation codes along with prolonged psychiatric evaluation codes.

The CMS Waiver

Under the CMS waiver, telehealth services may be now be provided in all areas (not just rural), and any Medicare beneficiaries may receive these services from any location, including their homes. This applies to both new patients and those with whom the furnishing physician has a pre-established relationship under the waivers

During the pandemic, CMS will reimburse for audio-only telephone calls.

CMS has temporarily added separate codes (CPT codes 98966-98968 and CPT codes 99441-99443) to the list of approved telehealth services. 

Valued the same as the office and outpatient evaluation and management (E/M) codes.

Telephone services should not be reported for a follow up call related to a procedure by your same group.

Clinicians may provide remote evaluation of patient video/images and virtual check-in services (HCPCS codes G2010, G2012) to both new and established patients. These services were previously limited to established patients.  Licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech language pathologists can provide e-visits. E-visits are non-face-to-face communications with their practitioner by using online patient portals. (HCPCS codes G2061-G2063).  Clinicians may provide remote patient monitoring services to both new and established patients. These services may be provided for both acute and chronic conditions and can now be provided for patients with only one disease. For example, remote patient monitoring can be used to monitor a patient’s oxygen saturation levels using pulse oximetry. (CPT codes 99091, 99457-99458, 99473-99474, 99493-99494).

As of early 2020, 32 states and the District of Columbia had laws requiring private payers to reimburse for telehealth services. 49 states and the District of Columbia provide reimbursement through Medicaid. The coverage varies by state, payer type, and individual characteristics of the encounter (patient setting, geographic location, type of provider, live video vs. electronically transmitted health information).  As clinical practice in the emergency department grows to accommodate telehealth technology, the code set will require ongoing review and expansion.

CMS has recently confirmed that there are no specialty specific restrictions on billing for Telehealth consultation, emergency department or initial inpatient, HCPCS codes G0425-G0427, so emergency physicians could bill for these services if they are the consulting provider, as demonstrated in the 2 examples below:

1. Emergency physician in a non-trauma designated hospital ED has a major trauma such as a roll over motor vehicle accident present to the ED.  He/She calls another emergency physician at a Level 1 trauma center to discuss management and potential transfer of the patient. The patient is not transferred and remains in the smaller facility with significant input and direct management by the physician at the level 1 trauma center.
2. Emergency physician in a smaller hospital ED sees a complex sepsis, stroke, or acute MI patient and calls an emergency physician at a larger academic medical center to discuss management of the patient and potential transfer  of the patient. The patient is not transferred and remains in the smaller facility with significant input and direct management by the physician at the level 1 trauma center.

Claims for professional services should be submitted using the appropriate service code, and the modifier "GT" or “GQ.”

GT modifier- Providers at the distant site submit claims for telemedicine services using the appropriate CPT or HCPCS code for the professional service along with the modifier GT, “via interactive audio and video telecommunications system” (e.g., G0426 GT). Appending the GT modifier with a covered procedure code indicates that the distant site physician certifies that the beneficiary was present at an eligible originating site when the service was furnished.

GQ modifier- Providers participating in the federal telemedicine demonstration programs in Alaska or Hawaii must submit the appropriate CPT or HCPCS code for the professional service along with the modifier GQ, “via asynchronous telecommunications system.”

NOTE:  While Medicare contractors may require the GT or GQ modifier and do not allow CPT consultation codes, some private payers request CPT consultation codes without the Medicare modifiers.  Medicaid policies also vary state to state.  Since payer polices vary, you are advised to check with the local payers with which you participate regarding use of these modifiers or modifier -95 Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System.

Yes.  In order to report remote video-conferenced critical care, the physician(s) in the distant site must have real-time access to the patient's medical record including progress notes, nursing notes, medications, vital signs, laboratory tests, and radiographic images. The physician must also be able to enter orders, video-conference with the on-site health care team, speak to family members, and observe the patient.  The review and/or interpretation of diagnostic information is included in reporting remote critical care and should not be reported separately.

Critical care E/M codes (99291 and 99292) describe critical care services provided at the bedside and environs were approved by CMS for the COVID public health emergency. Remember to apply the appropriate modifiers.

Non-Medicare payers may want you to report telemedicine services using Medicare’s HCPCS codes as described above or the regular Emergency Department E/M CPT codes with either the GT or 95 modifier, or no modifier. You are advised to contact your local carrier for final instructions on billing telemedicine services.

1. Centers for Medicare and Medicaid Services. “Telemedicine and Telehealth.” Available online at: http://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/index.html?redirect=/telehealth 
2. ACEP Emergency Telehealth Section. https://www.acep.org/telehealth/

See Separate COVID-19 Teleheath Waivers FAQ