TeleHealth/TeleMedicine Update 3-17-20

New Day New Rules

Our previous articles posted Friday and Monday have been replaced.

Telehealth Changes with COVID–19Published March 14, 2020
TeleHealth Update for COVID 19Published March 16, 2020

As many of you now know CMS has relaxed the requirements for the provision of TeleHealth and TeleMedicine services. CMS has taken this one step further and has relaxed HIPAA requirements relative to the use of technology to provide these services. Here a few important facts. For Purposes of this Update, I am going to break the update into sections: Medicare Telemedicine, Medicare Telehealth and Private Payers.  

Medicare TeleMedicine – Encounter using live video and audio interaction for the visit.  

  • Established patient office visits 99212-99215 can be reported for remote office services provided to any patient regardless of location as long as the visit is conducted using a live audio and visual connection. Documentation for the visits must meet the same requirements as office visits and are based on time or components. Payment for each code will be made at the same level as if the service were provided in the office. Billing requires only that you report the code for the visit and report the place of service as 02 instead of 11 (the Place of service code for office).
  • HIPAA rules have been relaxed as well. You are free to use FaceTime and Skype to conduct these visits without a BAA. You are required to take reasonable precautions such as avoiding the provision of these visits with others in the room who are not employed by your office. Further, we encourage you to respect your patients, explaining the purpose of others required in the room. If you have HIPAA compliant tools you should use them when possible.  
  • Should you choose you may waive co-payments for these visits (Insurance Only visits). Be careful to be consistent when offering this to patients. This option has been announced and may be expected by patients. You may wish to develop a process for Telemedicine visits that includes having the front desk speaking with the patient about billing and payment, having an MA or nurse assisting you to collect relevant history complaints and making sure that the video and audio connection is of sufficient quality and finally commence the visit with the physician. The first two steps up until the establishment of the connection can be conducted with audio (telephone) only and can be accomplished before the visit similar to the flow established for an in-office visit.  
  • CMS has indicated that you are restricted to providing these visits to patients with whom you have an existing relationship. Note that it is possible to have a relationship with a patient and still report services under the New Patient Codes (99201-99205), consider those patients that were last seen over 4 years ago. Documentation requirements are the same regardless if the service is provided face to face or remotely. It is therefore expected that a comprehensive physical examination is unlikely thus level 4 and 5 codes are not likely for these visits. New Patient codes reported as TeleMedicine services should be paid. However, Medicare has included the following in the released statement: “To the extent the 1135 waiver requires an established relationship, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency.” The implication appears to imply that in urgent and medically necessary situations reporting a New Patient visit for a patient with no prior relationship will be tolerated. Report qualifying encounters with the appropriate E/M code with place of service 02. 
  • Typical non-urgent New Patient visits should be considered as not medically necessary. If you choose to provide these services you may be able to obtain an ABN for the visit. Signature of the ABN can be accomplished via a patient portal. Under the relaxation of HIPAA during the crisis, you should be able to use services like Docusign to acquire patient signatures and other documents normally required when a new patient joins the practice. It also appears that you would be able to send forms via email and receive a scanned document (encrypted if possible) or returned via picture and messaging to the office (use this a last resort). Numerous applications can be used, such as What’s App, that allow pictures to be sent directly from a phone to a computer instead of using mobile phones in the office. Charges for these visits must not exceed Medicare rates for your area and are the responsibility of the patient. Report these services with the appropriate E/M code with modifier -GA and place of service 02.

Medicare TeleHealth – services provided using a telephone only or through web services such as patient portal or encrypted email (or standard email as a last resort during the crisis).

Codes G2012 is available for reporting telephone calls between a Physician or APP and a patient. This code can be reported to Medicare if the following are met:

  • The patient is an established patient.
  • The phone call does not result in the Physician or APP directing the patient to visit the office within the next few days to treat the problem.
  • The patient is aware that Medicare will be charged for the call before the call and the patient is responsible for co-payments or deductibles.
  • The phone call was not the result of an E/M visit that happened within the previous 7 days.  
  • The request for the visit was initiated by the patient.  

Codes G2010 is available for reporting the review of data or images provided by the patient and sent to and responded to by Physician or APP. The response can be within 24 hours of receipt of the information and can be provided via telephone or messaging. This code can be reported to Medicare if the following are met:

  • The patient is an established patient.
  • The data review l does not result in the Physician or APP directing the patient to visit the office within the next few days to treat the problem.
  • The patient is aware that Medicare will be charged for the call before the call and the patient is responsible for co-payments or deductibles.
  • The data request was the not result of an E/M visit that happened within the previous 7 days.  
  • The request for the visit was initiated by the patient.  

Codes 99421-99423 for physician or APP interactions with the patient and G2061-G2063 for those employed by and under the supervision of a physician or APP (eg. Nursing staff etc.)

These codes can be reported to Medicare if the following are met:

  • The patient is an established patient.
  • The services are provided via HIPAA complaint means – Patient Portal or encrypted email (or standard email as a last resort during the crisis) over a 7 day period. 
  • Time is based on cumulative time spent during the 7 day period. Documentation is expected to support the code reported.
  • The patient is aware that Medicare will be charged for the call before the call and the patient is responsible for co-payments or deductibles.
  • The request for advice via the portal was initiated by the patient.  

CMS has stated clearly that physician offices can actively encourage patients to initiate a request for these services. In short, you can message the patients and encourage them to call or seek assistance via the web portal for these services. (As stated in previous releases.)

Private payers

Medicare Advantage – Medicare Advantage plans are expected to allow for coverage under Medicare guidelines or establish less stringent guidelines. Check payer websites for guidance. Some Medicare Advantage plans may allow for New Patient visits. Some payers may allow telephone visits for established patients to be reported with established patient visit codes (99212-99215). Billing for Medicare Advantage plans will require only the use of the appropriate CPT code with place of service 02.

Medicaid – Medicaid programs are directed by the state. You will need to check with your state Medicaid program for coverage rules and billing for TeleMedicine and TeleHealth services. 

Commercial Plans – Many commercial payer plans have policies that follow Medicare guidelines as they are published. With the emergency declaration, we expect that many private payers will follow suit. You will need to check payer websites for updates. We maintain the following recommendations for private payers based on your coverage findings. 

Patients with private payer coverage offering TeleMedicine/TeleHealth coverage:

  • Can be offered and encouraged to initiate visits via telephone or through the portal.  Messaging should be developed to encourage patients to call and cancel appointments if they feel uncomfortable or to comply with state and local directives.
  • Patients should be told that many of their health needs can be addressed during this time of crisis via telephone or through your web portal. 
  • Patients may be encouraged to contact the office or insurance plan for information regarding co-payments and deductibles. Report the appropriate CPT code with place of service 02 and modifier -95 or -GT as required. 

Patients with private payers with no TeleMedicine/TeleHealth benefits:

  • Can be offered and encouraged to initiate visits via telephone or through the portal. Messaging should be developed to encourage patients to call and cancel appointments if they feel uncomfortable or to comply with state and local directives.
  • Patients should be told that many of their health needs can be addressed during this time of crisis via telephone or through your web portal.
  • Patients in this category will also need to be told that their payers do not offer telehealth benefits. Therefore, services will be provided on a fee for service basis. 
  • Develop and communicate policies and pricing for these services. (pricing should not appear inflated and should reflect compassionate care and access concerns.) This may include a requirement for the patient to sign a form indicating their understanding of the direct bill process and service for the date (modified ABN). The patient may elect to attempt to collect from the payer for these services. Report the appropriate CPT code with place of service 02 to the patient for payment.  

Patients with Private payers with unclear TeleMedicine/TeleHealth benefits:

  • Can be offered and encouraged to initiate visits via telephone or through the portal.  
  • Messaging should be developed to encourage patients to call and cancel appointments if they feel uncomfortable or to comply with state and local directives.
  • Patients should be told that many of their health needs can be addressed during this time of crisis via telephone or through your web portal. 
  • Patients in this category will also need to be told that their payers are not clear on their coverage for telehealth benefits. Therefore, services will be provided on a fee for service basis. The office will ask the patient to sign a document for each service indicating that the service will not be billed to your insurance and is solely the responsibility of the patient. Develop and communicate policies and pricing for these services. (pricing should not appear inflated and should reflect compassionate care and access concerns.)

NOTE: Under HIPAA patients have a right to pay directly for services rendered. If the payment is made in full and not charged to the insurance company the patient will need to sign a release form to allow the release of the medical record for that visit to the insurance company. Report the appropriate CPT code with place of service 02 and modifier -95 or -GT as required. 

Codes Mentioned in the Article with Descriptions

CodeStatusGlobalDescription
99201AXXXOffice or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
99202AXXXOffice or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family.
99203AXXXOffice or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.
99204AXXXOffice or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.
99205AXXXOffice or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.
CodeStatusGlobalDescription
99212AXXXOffice or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
99213AXXXOffice or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.
99214AXXXOffice or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.
99215AXXXOffice or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.
CodeStatusGlobalDescription
99421AXXXOnline digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
99422AXXXOnline digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes
99423AXXXOnline digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes
CodeDescription
G2010 Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment
G2012Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
G2061Qualified nonphysician healthcare professional online assessment, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes
G2062Qualified nonphysician healthcare professional online assessment service, for an established patient, for up to seven days, cumulative time during the 7 days; 11-20 minutes
G2063Qualified nonphysician qualified healthcare professional assessment service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes
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Mark N. Painter is a managing Partner of PRS Consulting, LLC, the CEO of PRS, LLC and the Vice President of Coding and Reimbursement Information for Physician Reimbursement Systems, Inc. (PRS). Since co-founding PRS in 1989, Mr. Painter has served as the primary coding resource for the PRS products including Hotlines, Coding Manuals and quick reference tools, the Internet based application codingtoday.com and seminars. He has lectured to a variety of groups concerned with health care reimbursement. Mr. Painter's extensive knowledge of physician reimbursement issues has allowed him to assist insurance companies, physicians and their staff members, legal counsel, actuaries, Specialty Societies and consultants on a daily basis. He has serves has an expert to legal counsel, bio device companies and pharmaceuticals. He was a co-chair of the Colorado Clean Claims Task Force, a committee of nationally known industry experts charged with the development of single payment edit database for the state. Mr. Painter is a CPMA. Mr. Painter received his B.A. from Grinnell College at Grinnell, Iowa.