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Telehealth and Your Practice, Then, Now and Post-pandemic

Coding ToolsCodingTelemedicine
Apr 28, 2021
David Holtz, MD and Kristine Zanotti, MD

Although telehealth technology has been around for a long time, until recently its widespread use has been limited due to restrictive and often confusing regulations. David Holtz, MD, and Kristine Zanotti, MD, have developed the following resources to meet the challenges of telehealth billing.

Telehealth: Benefits, Barriers and COVID 19 Pre/Post Practice Implications
Services That are Within the Umbrella of Telemedicine Technology
Frequently Asked Questions (FAQ)
What are the Billing Codes Used for These Services?
Additional Resources

Telehealth: Benefits, Barriers and COVID 19 Pre/Post Practice Implications

During this time, adopting telehealth in your practice will reduce COVID exposure for you, your patient, and your staff. Among the many proven additional benefits of telehealth are:

  1. Improving access for all patients to your specialized services
  2. Reducing disparity in health care access
  3. Increasing practice efficiency
  4. Reducing patient costs
  5. Reducing patient no-shows
  6. Improving patient satisfaction

Potential limitations of telehealth

  1. Situations in which in-person visits are more appropriate due to patient clinical acuity, or reduced ability to perform an adequate physical exam
  2. Patient access to technological devices (e.g., smartphone, tablet, computer) needed for a telehealth visit or connectivity issues
  3. Patient level of comfort with technology
  4. The need to address sensitive topics if there is patient discomfort or concern for privacy
  5. Challenges integrating teaching in a clinical training environment

Noteworthy among the pre-COVID barriers to telehealth were:

  1. Significant restrictions on the types of services/clinical encounters that were allowable/covered with telehealth
  2. Substantial restrictions for whom the telehealth services could be provided. Telehealth was restricted to those who lived in a rural/underserved area. To qualify for telehealth, the patient had to live a specified geographic distance from a tertiary health care center
  3. Perhaps the greatest restriction, was the restrictions on how the telehealth encounter could be provided. Patients living in a rural area had to be at a local qualified medical site (physician office, skilled nursing facility or hospital) to receive the telehealth encounter
  4. Provider to patient home telehealth was not allowable/reimbursable by CMS. With substantial regulatory restrictions, provider to home telehealth was a viable option only if patients paid out-of-pocket or employers/insurers contracted specifically for such services with significant limitations on the spectrum of providers and services available
  5. There were cumbersome and costly credentialing requirements for clinicians providing telehealth services to these remote locations

COVID-19 Pandemic and Telehealth Changes
In response to the COVID pandemic, The Coronavirus Aid, Relief, and Economic Security Act (also known as the CARES Act) was passed by the 116th U.S. Congress and signed into law on March 27, 2020. Among the provisions in this $2.2 trillion economic stimulus bill was the removal of many of the prior barriers to the widespread use of telehealth during the Public Health Emergency (PHE). It should be noted that the nationwide declaration of a PHE was renewed by the Department of Health and Human Services on October 23, 2020, and an endpoint has not yet been specified.

Note: CMS issued multiple waivers for Medicare. However, Medicaid programs are administered at the state level. Thus, always complicating matters is that every private insurance plan and many state funded Medicaid plans have different sets of rules as to what types of telemedicine practitioners/providers may be covered/reimbursed, and how much to reimburse for telemedicine services. Since the passage of the CARES Act, the Centers for Medicare & Medicaid Services (CMS) prior barriers CMS developed this Medicaid & CHIP Telehealth toolkit to help each state accelerate their adoption of telehealth. Many states have since issued their own PHEs, resulting in changes to state-run Medicaid services and licensure for telehealth. Many private insurers soon followed suit.

Thus, while many states chose to template CMS provisions, providers must be aware of potential differences. The below resources have been developed to help providers better understand policies and restrictions within their own state.

  • The Center for Connected Health Policy (CCHP) has 2 resources that track COVID-19 Telehealth Coverage Policies and COVID-19 Related State Actions, which include Medicaid clarification, waivers, and telehealth guidance, prescription and consent waivers, private payer requirements, and cross-state licensing
  • The Alliance for Connected Care also has created a reference chart describing state changes to licensure, coverage, and other changes

Services That are Within the Umbrella of Telemedicine Technology

There is a spectrum of services that fall under the category of Telemedicine technology. These include:

  1. Real-time, audio-video communication tools (telehealth) that connect physicians and patients in different locations
  2. Verbal/Audio-only phone encounters
  3. Virtual Check-ins and E-visits via patient portals and other secure messaging technologies
  4. Store-and-forward technologies that collect images and data to be transmitted and interpreted later
  5. Remote patient-monitoring tools such as blood pressure monitors, Bluetooth-enabled digital scales and other wearable devices that can communicate biometric data for review (which may involve the use of mHealth apps)

This review will address provider to the patient encounters types described in 1 and 2 and 3. These differ in the platform utilized by patient and provider, the services provided, and whether the communication with the patient is in real time or ‘asynchronous’.

Telehealth: 

  1. The service requires both audio and video transmission
  2. The communication is occurring in real time, with a 2-way exchange between both provider and patient
  3. The communication/encounter provides an E/M service

 Telephone visit:

  1. The service is an audio-only communication
  2. The communication is occurring in real time, with 2-way exchange between provider and patient
  3. The communication/encounter provides an E/M service

 E-Visit

  1. The visit is via online secure digital communication.  Platforms may include:
    • Online patient portal
    • Secure email
    • Other digital telehealth platform
    • The communication is not via telephone or video
  2. The communication is asynchronous, not in real time
  3. The communication provides an E/M service

Virtual Check-in

  1. The virtual check-ins allow many different platforms. These platforms include:
    • Phone
    • Audio/visit
    • Secure text messages
    • Email
    • Patient portal
  1. The communication may be real time or asynchronous
  2. The communication provides and E/M service
  3. These encounters are paid at a rate to cover 5-10 minutes of medical discussion and intended to provide a platform for clinicians to give brief medical advice for straightforward problems or to triage the need for additional more in-depth medical evaluation

The caveat is that this communication must not be related to a medical visit within the past 7 days.  Also, if the discussion leads to a subsequent visit, the virtual check in visit will then not be billable.

Frequently Asked Questions (FAQ)

The federal government has taken concrete steps to make telehealth services easier to implement and access during this national emergency. These changes are temporary measures during the COVID-19 Public Health Emergency and are subject to revision.  Below addresses many frequently asked questions, comparing past restrictions on services with those allowable during the PHE and also speculating about possible changes that may occur post-PHE.

Who can provide these services?

Pre-COVID PHE During COVID PHE After COVID PHE
Who can provide telehealth services? CMS regulatory requirements largely restricted telehealth services to ‘provider to facility’ encounters.  These compelled the practitioner to be credentialed separately at each remote facility.  This expensive and cumbersome regulatory requirement was a significant barrier to providers participating in telehealth care. CMS relaxed restrictions to allow ‘provider to home encounters. Thus, with the PHE, practitioners who can provide an E/M visit can provide a telehealth encounter. These included physicians, nurse practitioners, physician assistants, nurse midwives, clinical psychologists, clinical social workers, registered dieticians and physical therapists. Interstate licensure challenges and other regulatory issues vary by state. Currently, it is unclear whether the wide spectrum of providers and services that are currently allowable by CMS under COVID will remain after the PHE is declared over.  However, it is very unlikely that CMS will to return to pre-COVID restrictions.

What services are eligible for telehealth?

Pre-COVID PHE During COVID PHE After COVID PHE
What services are eligible when furnished via telehealth? Payable telehealth services were limited to those included on CMS’ Covered Telehealth Services list.  Pre-COVID, the list of allowable services was fairly restricted. CMS greatly expanded its list of services eligible for telehealth coverage to include many other visit types. These include office visits by MD and Advanced Practice Providers, emergency department visits, initial nursing facility and discharge visits, home visits, therapy services, and others. See CMS’ updated Covered Telehealth Services List for all services payable during the PHE. CMS is not proposing to continue payment for Medicare audio-only visits after the conclusion of the COVID-19 PHE. CMS does not have the authority to permanently waive the requirement for two-way, audio/video communications. CMS will receive comments on whether it should develop coding and payment for a service similar to a virtual check-in.

Are new patient encounters eligible?

Pre-COVID PHE During COVID PHE After COVID PHE
Telehealth services required an established relationship between the physician and provider for such services to be covered under Medicare. During the Public Health Emergency, CMS will not conduct audits to ensure that a prior physician/patient relationship existed for claims submitted during the PHE. Thus, functionally, both new and established patients are allowable for telehealth services during the PHE. CMS is likely to resume audits to ensure that a prior physician/patient relationship existed for claims submitted during the PHE.

What is the cost to the patient?

Pre-COVID PHE During COVID PHE After COVID PHE
What is the cost to the patient? Medicare beneficiary cost-sharing obligations (i.e., coinsurance and deductibles) apply to telehealth encounters.

 

Waiving of cost-sharing was considered an “inducement” and was not allowed.

Medicare beneficiary cost-sharing obligations still apply. However, during the PHE physicians may choose to reduce or waive any cost-sharing for telehealth services. It is likely that Medicare will return to pre-COVID cost sharing requirements.

 

Currently, many private payors have already rolled back these policies and have returned to cost-sharing for telehealth services if the encounter is for non-COVID reasons.

How are these telehealth encounters reimbursed?

Pre-COVID PHE During COVID PHE After COVID PHE
How is telehealth reimbursed compared to in-person visits? Historically, telehealth was reimbursed at a lower rate than in-person care. The CARES Act addressed this payment disparity by mandating the same rate for telehealth visits as in-person visits for those insured by Medicare, being reimbursed at the same rate as regular in-person services based on usual E/M criteria. It is likely that E/M services will return to being reimbursed at lower rates.

 

Currently, many private payers initially followed Medicare rates but have already rolled back these policies returned to reimbursing telehealth services at lower rates if the encounter is for non-COVID reasons.

What are the Billing Codes Used for These Services?

Telehealth Visits

CPT Code Description wRVU Approximate Reimbursement
99201 Outpatient/Office

New

0.49 $47
99202 0.93 $79
99203 1.42 $115
99204 2.43 $174
99205 3.17
99211 Outpatient/Office

Established

0.18 $23
99212 0.49 $47
99213 0.97 $77
99214 1.50 $124
99215 2.11 $153
99024 Post op (Global) n/a n/a

Modifier -95 (Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System) should be added to these E&M codes. CMS is reimbursing telehealth visits at parity to in-office E&M visits during the public health emergency declared for COVID- 19. This pay parity will not extend past the PHE unless enacted by Congress.

Telephone E/M

CPT Code Description wRVU Approximate Reimbursement
99441 Telephone E&M; 5-10 minutes of medical discussion 0.49 $46
99442 Telephone E&M; 11-20 minutes of medical discussion 0.97 $75
99443 Telephone E&M; 21-30 minutes of medical discussion 1.50 $110

Virtual Check-in

CPT Code Description wRVU Approximate Reimbursement
G2012 Brief communication (5-10 minutes) technology-based service, established 0.25 $23
G2010 Remote evaluation of recorded video and/or images submitted, established, including interpretation and follow-up within 24 business hours 0.18

Remote, audio and video enabled medicine has been a great service to our patients during the public health emergency of 2020. CMS has announced continued support for Telehealth visits for 2021 or until the declared end of the pandemic. We shall have to see if CMS allows for generalized use of virtual visits in the future, or if they will again be restricted based on provider, geography, and timing in a patient’s care.

Additional Resources

CMS:
Medicare and Medicaid Fact Sheet

SGO:
Telemedicine coding examples
Webinar: Crucial Conversation and Managing Pandemic Panic

AMA:
AMA Quick Guide to Implementing Telehealth in Practice

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