Coding Scenario: Coding for Telehealth Visits

Telehealth Visits

Note: These tables are informational, not advisory. The AAFP recommends that physicians verify each payer's policy and ask patients to verify their coverage ahead of appointments.

How do I code a new or established patient telehealth visit that uses audio-video or audio-only for COVID-19-related care?

*Anthem's policies vary by state; contact your provider-relations representative.

*Medicare requires audio-video for office visit (CPT 99201-99215) telehealth services. Audio-only encounters may be billed using the appropriate Telephone Evaluation and Management code.

How do I code a new or established patient telehealth visit that uses audio-video or audio-only for non-COVID-19-related care?

*Anthem's policies vary by state; contact your provider-relations representative.

**Medicare and UHC Medicare Advantage require audio-video for office visit (CPT 99201-99215) telehealth services. Audio-only encounters may be billed using the appropriate Telephone Evaluation and Management code.

Telehealth Scenario Notes

A full list of Medicare telehealth services is available here. Private payers vary on covered telehealth services. Check with your provider relations representatives for each payer’s telehealth policy and covered telehealth services.

Telehealth services can be provided to new and established patients via smartphone if the smartphone allows for audio-video interaction between the physician and patient.

Originating site restrictions have been lifted. Telehealth services can be provided to all patients regardless of originating site, including patients at home.

Office visits provided via telehealth will be paid at the same rate as in-person visits when the appropriate POS is used. Practices should use the POS they would have used if the service had been provided in-person. Claims with “POS 02 – Telehealth” may be paid at a lower rate.

• Some payers are automatically reprocessing claims that were submitted with the “POS 02 – Telehealth.” Contact your provider relations representative to verify if the payer is automatically reprocessing claims or if you will need to resubmit claims.

Medicare and most national payers will pay the full contracted/allowed amount when cost-sharing is waived. The “CS” modifier is required to trigger full payment of the allowed amount. Claims missing the “CS” modifier may not be paid at the full allowed amount.

COVID-related services include:

• COVID-19 Testing
  • An in vitro diagnostic test for the detection of SARS-CoV-2 or the diagnosis of COVID-19. The test must be approved, or the developer has requested or intends to request emergency use authorization under the Federal Food, Drug, and Cosmetic Act;
  • a test that is developed in and authorized by a state that has notified the secretary of Health and Human Services (HHS) of its intention to review tests intended to diagnose COVID-19; or
  • other tests the secretary of HHS determines appropriate in guidance.
• Items and services furnished to an individual through office visits (in-person and telehealth), urgent care center visits, and emergency room visits that result in an order for or administration of a COVID-test. Items and services must be related to the furnishing or administration of the test or to the evaluation of the patient for the purposes of determining the need for a COVID-19 test.

COVID-19-related services should be assigned the appropriate COVID-19 ICD-10 diagnosis code. Coding guidance can be found on the CDC website. Cost-sharing waivers may not be applied to claims that do not include an appropriate COVID-19 ICD-10 diagnosis code.

Some payers are allowing practices to provide telehealth office visits to provide using audio-video or audio-only communications. These visits should be coded as a typical telehealth visit as outlined above.

• The applicable coding requirements must be satisfied for the visit. Physicians should determine whether they can complete all required elements of their normal E/M service via audio only or whether the services should be submitted as a telephone E/M code.
• Aetna will cover minor acute care services delivered via audio-only.
• UHC will allow audio-only visits telehealth services for Medicaid and commercial patients. The requirements for Medicare Advantage members align with Medicare’s policy (below).
• Medicare requires audio-video for office visit (CPT 99201-99215) telehealth services. Audio-only encounters can be provided using the telephone evaluation and management codes (CPT codes 99441-99443).

CMS has updated the documentation requirements for outpatient E/M services delivered via telehealth.

• For the duration of the public health emergency, CMS will allow physicians to select the level of outpatient E/M furnished via telehealth based on medical decision making (MDM) or time.
  • Time is defined as all time associated with the E/M on the day of the encounter. This is similar to the updated guidelines for office/outpatient E/M codes scheduled to go into effect January 1, 2021.
  • Physicians should use the times listed in the 2020 office/outpatient E/M code descriptors when using time to select the level of service.
    
  • CMS is maintaining the current definition of MDM.
• CMS has removed any requirements regarding documentation of history and/or physical exam in the medical record for such visits.

If exchanged asynchronously, videos, images and communications must be stored and retained according to state regulation.

Real-time (synchronous) videos, such as during a video visit or video phone call, are not required to be stored.

Self-funded plans can develop their own policies and may opt out of some cost-sharing waivers. Similarly, Medicaid policies are established at the state level. The AAFP recommends reaching out to your provider relations representatives or Medicare Administrative Contractors (MACs) to verify policies. The Center for Connected Health Policy is tracking COVID-19 Related State Actions

Annual Wellness Visits

The Medicare AWV codes (HCPCS codes G0438 and G0439) are on the list of approved Medicare telemedicine services. CMS states that self-reported vitals may be used when a beneficiary is at home and has access to the types of equipment they would need to self-report vitals. The visit must also meet all other requirements.

Commercial and private payers may have different policies. Please check with your provider relations representatives for additional guidance.

Federally Qualified Health Centers and Rural Health Clinics

CMS has released guidance allowing federally qualified health centers (FQHCs) and rural health clinics (RHCs) to provide distant-site telehealth services. Telehealth services can be provided by any practitioner working for the FQHC or RHC within their scope of service, and there are no restrictions on where the service is provided, meaning physicians or practitioners may provide the service from their homes.

The payment rate for telehealth services furnished by an FQHC or RHC practitioner is $92. FQHCs and RHCs must use the -95 modifier for distant-site services provided between Jan. 27 and June 30, 2020. FQHCs will be paid their Prospective Payment System (PPS) rate, and RHCs will receive their all-inclusive rate (AIR). Claims will be automatically reprocessed in July, when the Medicare claims processing system is updated with the new rate.

For distant-site services provided between July 1, 2020, and the end of the COVID-19 public health emergency, FQHCs and RHCs should use HCPCS code G2025 to identify the services furnished via telehealth.

CMS is waiving cost-sharing for services related to COVID-19 testing, FQHCs and RHCs should append the -CS modifier to claims related to COVID-19 testing. Coinsurance should not be collected from beneficiaries when cost-sharing is waived. MACs will automatically reprocess these claims beginning on July 1.

In-Person

Virtual-Digital

Audio-only