Telehealth and telemedicine can be confusing to navigate, especially during the COVID-19 pandemic. We have gathered our top questions to get you the exact information you need to bill and code telehealth correctly.
The originating site is where a patient is located when they receive telehealth services. These normally must be clinical settings, such as physician offices and hospitals. Additionally, the originating site normally must be in a county located outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract to be eligible for telehealth services.
For the duration of the public health emergency (PHE), the Centers for Medicare & Medicaid Services (CMS) is waiving the geographic and originating site restrictions. Patients may receive telehealth services in any setting, including their homes.
The Department of Health and Human Services (HHS) Office for Civil Rights will waive penalties for Health Insurance Portability and Accountability Act (HIPAA) violations against health care professionals serving patients in good faith via nonpublic-facing everyday communication technologies, such as FaceTime or Skype, during the COVID-19 PHE.
For the duration of the PHE, Medicare is waiving and will cover cost-sharing for COVID-19 diagnostic tests and visits related to COVID-19 testing. Additionally, physicians may voluntarily waive cost-sharing for non-COVID-19-related telehealth and virtual/digital services. However, Medicare will not pay any cost-sharing waived at a physician’s discretion. Read the coding and reporting guidelines from CMS here.
Cost-sharing policies for private payers vary by payer. For more specific guidance, see this release from CMS. Review the Private Payer FAQ or contact your provider relations representative for additional information.
Note: Self-funded plans may opt out of some cost-sharing waivers. Similarly, Medicaid policies are established at the state level and may differ from national policies.
The Coronavirus Aid, Relief, and Economic Security (CARES) Act and the Families First Coronavirus Response Act require Medicare and group health plans to cover diagnostic testing related to COVID-19 at no cost to patients for the duration of the PHE. As defined by the laws, COVID-related services include:
Please see the Private Payer FAQ for additional information on coding COVID-19-related visits.
For the duration of the PHE, CMS will cover telephone evaluation and management (E/M) services (CPT codes 99441-99443). For Medicare patients, on an interim basis, the relative value units and payment amounts will align as follows: 99441 will align with 99212, 99442 will align with 99213, and 99443 will align with 99214.
Additionally, a select group of services can be provided using an audio-only connection. However, the audio-video requirement remains in place for most services, such as office visit E/M services. An updated list of telehealth services that shows which services may be provided using audio-only can be found on this CMS webpage.
Private payers also cover telephone E/M services. Their policies on audio-only office visit E/M services vary. More information can be found in the Private Payer FAQ or by contacting your provider relations representatives to verify policies.
Physicians should bill the visit that most appropriately describes the service. If the visit is conducted primarily via audio, it would be appropriate to use the applicable telephone E/M code (CPT codes 99441-99443).
No. If a telephone visit lasts more than 30 minutes, physicians should bill the CPT code 99443.
Yes — if they are coded correctly. Visits must be coded according to each payer’s guidance. Visits that are not coded correctly may be denied or paid at a lower rate. For the duration of the PHE, CMS will pay office visit/outpatient E/M services provided via telehealth at the same rate as an in-person office visit. Additionally, CMS will pay telephone E/M services (CPT codes 99441-99443) at parity with office visit E/M codes of comparable length. Payment will range from $56 to $130.
Please see the Private Payer FAQ for additional information.
To ensure proper payment, the AAFP recommends that practices update their billing system's allowable amounts to reflect the updated payment rates. Claims submitted with the previous, lower amounts may not be paid the full amount, since payers often pay the lesser of the allowed amount and the actual charge.
Medicare is waiving patient cost-sharing for services related to COVID-19 testing during the PHE. Medicare will pay 100% of the allowable, so physician payment is effectively not reduced. Physicians should use the CS modifier on the claim lines for services related to COVID-19 testing. Physicians may waive cost-sharing for non-COVID-related telehealth services and telephone E/M services (CPT codes 99441-99443). However, Medicare will not pay any cost-sharing voluntarily waived by the physician at their discretion.
Private payer policies vary. Review the Private Payer FAQ or contact your provider relations representative for additional information.
Note: The HHS Office of Inspector General has said it’s permissible for physicians to routinely waive Medicare cost-sharing for telehealth services during the PHE, even if they are not COVID-19-related. In that case, it’s the physician’s choice, and if they waive the cost-sharing, that would represent lost revenue, since Medicare will pay only its portion.
Medicare’s cost-sharing waivers are in effect until the end of the PHE. The PHE is currently set to expire April 20, 2021.
Expiration dates for private payers vary. Please review the Private Payer FAQ for additional information.
Verify that the claim was coded according to the payer’s requirements. Common causes of reduced payment or missing cost-sharing waivers include incorrect place of service and missing modifiers. Additionally, self-funded plans may opt out of a payer’s national policy. If the claim appears to be coded correctly, contact your provider relations representative.
Note: Resolving claim-level issues often requires the physician’s NPI and information from the claim. The quickest way to resolve a claim-level issue is through your provider relations representative. The AAFP monitors policy trends and is in regular contact with national payers.
The billing and coding requirements for telehealth and virtual/digital services vary by payer. Please review the Private Payer FAQ for additional information.
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.
The Welcome to Medicare visit (code G0402, “Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment”) is not on the list of approved Medicare telemedicine services.
Commercial and private payers may have different policies. Please check with your provider relations representatives for additional guidance.
Yes. CCM is already considered a non-face-to-face service. Patient consent is required. Verbal consent is sufficient and must be documented in the patient medical record. Patients who have not been seen in the office in the past 12 months must have an initiating visit, such as an office visit. The initiating visit may be provided via telehealth.
TCM is on Medicare’s list of covered telehealth services. Per Current Procedural Terminology (CPT), CPT codes 99495 and 99496 include one face-to-face (but not necessarily in-person) visit that is not separately reportable. CMS has not specifically addressed this question but is otherwise covering such visits as stand-alone services.
To date, CMS is not considering a phone (audio-only) visit equivalent to a telehealth visit involving audio and visual technology. Given that CPT describes the visit included in TCM as “face-to-face,” we do not advise conducting that visit as a telephone (audio-only) visit.
Telephone E/M (CPT codes 99441-99443) and e-visits (CPT codes 99421-99423) should not be billed during the same month as CCM or during the same service period as TCM.
No. Per CPT, total time for purposes of reporting the level of service for an office/outpatient visit evaluation and management code includes the face-to-face and non-face-to-face time spent by the physician and/or other qualified health care professional on the date of service and does not include time for services normally performed by clinical staff.
For the duration of the PHE, CMS has amended the teaching physician regulations to allow supervision by interactive telecommunications technology (i.e., real-time audio and video) to satisfy the requirement for the presence of a teaching physician for the key portion of the service. The medical record must reflect whether the teaching physician was physically or virtually present for the key portion of the service, including the specific portion of the service for which the teaching physician was present through interactive, audio/visual real-time technology. CMS will also allow teaching physicians to review the services provided with the resident during, or immediately after, the visit through interactive telecommunications technology. This exception is in place through the later of the end of the calendar year in which the PHE ends or December 31, 2021. All other policies continue to apply.
CMS will also temporarily allow all levels of office visit E/M services (CPT codes 99202-99205 and 99211-99215) furnished in a primary care center to be provided under direct supervision of the teaching physician by interactive telecommunications technology.
For the duration of the PHE, CMS will allow the following additional services under the primary care exception:
No. In its recent Interim Final Rule, CMS stated it believes virtual check-ins (HCPCS codes G2012 and G2010) are reportable only by physicians and practitioners (e.g., nurse practitioner or physician assistant), who can provide evaluation and management services as the service describes a check-in “directly with the billing [physician or] practitioner to assess whether an office visit is needed.”
As such, G2012 cannot involve only clinical staff (e.g., a nurse who is not a nurse practitioner) and be reported “incident-to.” Thus, the only way to capture phone calls between nurses who are not nurse practitioners and patients for Medicare billing purposes is to count the time toward an appropriate chronic care management code or transitional care management code.
Yes. Physicians and nonphysician providers may provide direct supervision via real-time, interactive audio/visual technology through the later of the end of the year in which the PHE ends or December 31, 2021.
Yes. For the duration of the PHE, CMS is allowing FQHCs and 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 services, and there are no restrictions on where the service is provided, meaning physicians or practitioners may provide the service from their homes.
For distant-site services provided between July 1, 2020, and the end of the COVID-19 PHE, 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.
Additional information can be found in this Getting Paid blog post.
For the duration of the PHE, CMS will cover monoclonal antibody treatments for beneficiaries who meet the following requirements:
People with Medicare pay no cost-sharing for COVID-19 monoclonal antibody infusion therapy.
Private payers’ policies vary. Review the Private Payer FAQ or contact your provider relations representative..
Yes. The Families First Coronavirus Response Act prohibits plans from imposing prior authorization requirements on COVID-19 testing for the duration of the PHE. Private payers are offering additional prior authorization flexibilities. Contact your provider relations representatives for their policies.
CMS will automatically apply the extreme and uncontrollable circumstances for the 2020 MIPS performance year. Additional information can be found on the Quality Payment Program website. CMS has not indicated whether the extreme and uncontrollable circumstances policy will apply to the 2021 MIPS performance year.
CMS will apply the MSSP extreme and uncontrollable circumstances to accountable care organizations (ACOs) for the 2020 performance year. Since the PHE was still in effect December 2020, shared losses for the 2020 performance year will be mitigated. The policy is also in effect for the 2021 performance year. CMS may make additional changes through future rulemaking. Please check with your ACO’s administration for additional information on quality reporting requirements.