New telehealth codes for 2025 have an invalid status indicator from Medicare

See the telemedicine section of CPT Coding Changes for 2025 for details.

Included in this article:

• Place of Service update from MLN Matters
• CPT® changes in 2025
• The Future of Telehealth and Virtual Care

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Place of Service:

The MLN Matters article updated April 2024 (MLN901705) provides this information about POS:

“Professional billing

Starting January 1, 2024, use:

• POS 02: Telehealth Provided Other than in Patient’s Home

Descriptor: The location where health services and health related services are provided or received, through telecommunication technology. Patient is not located in their home when receiving health services or health related services through telecommunication technology.

• POS 10: Telehealth Provided in Patient’s Home

Descriptor: The location where health services and health related services are provided or received through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology.

Starting January 1, 2024, we pay for telehealth services you provide to patients in their homes at the non-facility PFS rate.”

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CPT® Changes in 2025:

CPT® is adding 17 new CPT codes for audio only, audio/visual visits, in code range 98000–98016. These are divided into new and established patient visits and with either time or MDM definitions. The bad news: CMS  assigned  give 16 of these an invalid status indicator. That means, CMS will not recognize or pay for the new CPT telehealth codes. One, 98016,  would replace G2012 brief communications technology check in and CMS will accept that code and delete G2012 in 2025.

In the Final Rule released in November 2024, CMS again stated that it does not have the statutory authority to continue to allow telehealth using the flexibilities that were implemented during the pandemic. During the pandemic, CMS removed the requirement that the patient be located in an underserved area and that the patient go to a facility (originating site) to receive telehealth. Patients in all parts of the country could receive telehealth at home. CMS also added other therapists to the list of approved providers, including PT/OT, SLP, and audiologists.  In plain English: patients may no longer receive telelehealth in their homes. Patients may only receive telehealth in a geographically underserved area.

All of those flexibilities are slated to end Dec. 31, 2024, unless Congress steps in.

The exception is behavioral health. For behavioral health, due to an act of Congress patients may continue to receive telehealth via real time audio/visual communication and audio only.

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The Future of Telehealth and Virtual Care
Valerie Rock, CHC®, CPC® – Principal, Healthcare Consulting
Katie M. Baker, MSHA, CPhT – Manager, Healthcare Consulting

Introduction to Telehealth

The concept of telehealth has been around for many years, and, prior to the COVID-19 pandemic, it was used relatively sparingly by some providers and healthcare organizations who needed to meet the needs of patients who were in geographically distant locations. When the COVID-19 pandemic started in March of 2020, healthcare organizations were faced with the challenge of providing a high volume of services while simultaneously working through facility capacity constraints and quarantine protocols. As such, telehealth became a vital part of care delivery, allowing patients to be seen and treated within their homes by a multitude of healthcare providers. While the PHE has ended, the prevalence of telehealth shows no signs of slowing down. Telehealth has proven to be beneficial for increasing patient access; however, it comes with its own set of complexities related to compliant billing, collections, and administration.

Pre-COVID Medicare Telehealth Coverage

Prior to the start of the COVID-19 public health emergency (PHE), the Centers for Medicare & Medicaid Services (CMS) had some general requirements related to telehealth coverage. As outlined in Section 1834(m) of the Social Security Act[1], coverage for telehealth services must have met the following criteria:

1. Geography – The patient must have resided in a rural area.
2. Location – The patient must have been physically present at a healthcare facility when the service was provided (with associated facility fee billed).
3. Service – Coverage was limited to CMS’ list of approved telehealth services.
4. Provider – Services must have been provided by a physician, non-physician practitioner, clinical psychologist, clinical social worker, registered dietician, or nutrition professional.
5. Technology – Services must have been provided via telecommunications technology with audio and video capabilities that permitted real-time, interactive communication.

Despite the coverage requirements above, there were some exceptions, including:

• Telestroke services, which had their geographic and location requirements waived effective January 2019 for those services furnished to diagnose, evaluate or treat symptoms of acute stroke;
• End-stage renal disease (ESRD) services, which also had their geographic and location requirements waived effective January 2019 for those services relating to home dialysis;
• Substance use disorder (SUD) services, which had their geographic and location requirements waived in July 2019 for those services relating to SUD and/or co-occurring behavioral health conditions;
• Services billed to Medicare Advantage plans, as, beginning in the 2020 plan year, Medicare Advantage plans were permitted to begin waiving geographic and location requirements if required; and
• Services billed by organizations participating in down-side risk models for the Medicare Shared Savings Program (MSSP) or Center for Medicare and Medicaid Innovation (CMMI) initiatives.

Medicare Telehealth Coverage Expansion During PHE

As a result of the COVID-19 PHE, CMS elected to expand telehealth coverage to allow greater access for patients and remove barriers to care related to capacity constraints within healthcare facilities. Legislative action allowed the Secretary of the Department of Health and Human Services (HHS) to waive Section 1834(m) geography and location requirements for the duration of the PHE.

CMS also issued interim final rules that suspended certain service restrictions for the duration of the PHE as well. This included an expanded list of covered services, the elimination of frequency requirements, and permitted use of telehealth for previously required face-to-face visits, direct supervision for incident-to-billing, and teaching physician presence. Certain provider restrictions were also suspended, as CMS waived the state licensure requirement[2], permitted therapists and speech language pathologists to provide covered services via telehealth, permitted FQHCs and RHCs to bill for telehealth services under Healthcare Common Procedure Coding System (HCPCS) code G2025, and permitted billing for hospital outpatient department and critical access hospital services furnished via telehealth.

The interim final rules issued also authorized payment for certain audio-only evaluation and management (E/M) services (Current Procedural Terminology (CPT®) codes 98966-68, 99441-43) and provided reimbursement for telehealth services at higher non-facility rates to compensate practices for telehealth-associated costs.

In order to assist with the provision of service during the pandemic, other agencies followed suit and waived or suspended certain restrictions.

• The Office for Civil Rights (OCR) issued a Notice of Enforcement Discretion, stating they would not impose penalties if, in good faith, an organization used any non-public remote audio/visual communication product.
• The Office of Inspector General (OIG) also issued a Notice of Enforcement Discretion that permitted the waiver of co-insurance for associated services.
• The Drug Enforcement Administration (DEA) permitted the use of telehealth for in-person medical evaluation prior to prescribing scheduled II – V controlled substances.

As you can see, there was sharp increase in the number of telehealth users in Q2 of 2020, with nearly half of Medicare beneficiaries having at least one telehealth service during that time. The utilization has continued to level off, with total telehealth users dropping to 3.3M in Q4 of 2022; however, the 3.3M users is still well above the 1.6M in Q1 of 2020.[3]

Tele-Behavioral Health Services

Behavioral health services continue to be an exception to the rule. Through the Consolidated Appropriations Act (CAA) of 2021, geographic and location restrictions for diagnosis, evaluation, and treatment of mental health disorders were permanently waived. Patients must have an in-person, non-telehealth service by a practitioner in the same practice as the billing practitioner within the six months prior to the initial telehealth service and each twelve months thereafter.[4] There are some exceptions to the in-person visit requirement based on beneficiary circumstances (with reason documented in beneficiary’s medical record). Audio-only communication technology is permitted (as opposed to audio and video for other telehealth services) but only if the practitioner has audio and video capability and beneficiary lacks capacity or refuses to use video connection. This must be documented in the medical record and include a service-level modifier on the claim.

Extension of Flexibilities

Although the COVID-19 PHE has ended, many CMS flexibilities around telehealth coverage have been extended through December 31, 2024. These include:

• The continuation of the waiver of geographic and location requirements;
• The continuation of reimbursement for physical therapy, occupational therapy, speech language pathology, and audiologist telehealth services[5];
• The continuation of reimbursement for audio-only E/M CPT® codes (99441-43) and specified behavioral health and education services;
• A delay in the in-person requirement for initiation of tele-behavioral health services[6];
• The continuation of reimbursement to FQHCs and RHCs for medical telehealth services through CPT® code G2025; and
• The continuation of the use of telehealth to re-certify eligibility for hospice and required face-to-face encounter for home health.

There are some flexibilities that have not been extended however, including the permission to waive co-insurance for telehealth and virtual services. Additionally, organizations must comply with all HIPAA rules when providing telehealth services on a go-forward basis.

Effective January 1, 2024, organizations are required to begin using place of service (POS) 02 for telehealth provided other than in the patient’s home or POS 10 for telehealth provided in the patient’s home. Organizations may discontinue the use of modifier 95 and POS that would have been selected if the service had been furnished in-person. Additionally, POS 02 is to be paid at a lower facility rate and POS 10 is to be paid at a higher non-facility rate.

Organizations may no longer utilize telehealth for required face-to-face visits for home dialysis or inpatient rehabilitation facility patients; however, remember that for ESRD services, the geographic and location requirements were permanently waived in 2019, meaning this change would be for the required face-to-face visits only. Organizations may also no longer provide resident supervision via telehealth except in instances where the training program is located outside of the metropolitan statistical area (MSA) and the service is being furnished virtually (i.e., via three-way telehealth visit).

Medicare Physician Fee Schedule (MPFS) 2024 Updates

As guidance continues to shift and change post-PHE, there are several key updates resulting from the passage of the 2024 MPFS final rule. One of those includes changes to the covered telehealth services list, replacing Categories 1, 2, and 3 with permanent and provisional categories. CMS is also working to refine the process related to service eligibility for telehealth. At this time, all service categories (vs. Category 3 services only) added to the list during the PHE have been moved to the provisional category and there is no stated timeframe for removing these provisional codes from the list.

In addition to the extension of flexibilities previously noted, the 2024 MPFS Final Rule:

• Suspends frequency limitations for subsequent inpatient visits, subsequent nursing facility visits, and critical care consultations;
• Permanently eliminates the in-person requirement for injection training for Diabetes Self-Management and Training (DSMT) and expands the list of eligible DSMT distant site providers;
• Continues permitting opioid treatment programs to furnish periodic assessments via audio-only communications through the end of 2024; and
• Increases the originating site facility fee (Q3014) from $28.64 to $29.92.

Best Practices for Telehealth

As a result of these extensions and post-PHE changes, organizations should ensure their policies are aligned with current guidance. Additionally, organizations should continue to document E/M services as they would for an in-person visit, including a full patient history, examination, and medical decision making. Providers should also include a statement that the service was provided via telehealth, the HIPAA secure and OCR-approved platform that was used, where the provider and patient were located at the time-of-service delivery, and names and roles of any others participating.

Telehealth is here to stay and there continues to be expansion in the types of services that can be provided via telehealth, as well as the types of providers eligible to provide services via telehealth. In order to ensure you are compliantly billing and coding for telehealth services, consider implementing internal auditing and monitoring processes specific to telehealth to identify opportunities for improvement or additional provider/staff education. Stay up-to-date on telehealth requirements and changes by monitoring CMS resources and seeking additional guidance through webinars and other channels.

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About the authors

Valerie Rock, CHC®, CPC® – Principal, Healthcare Consulting

Valerie serves as a Principal on the Firm’s Revenue and Compliance Advisory Services team, specializing in physician coding, reimbursement, and regulatory compliance. With more than 15 years of experience in healthcare consulting, Valerie has assisted numerous clients with hospital-employed physician compliance and audit program development; physician and laboratory compliance program advisory support; statistically valid, sample-based refunds; physician and non-physician practitioner compliance; Medicare and Medicaid regulatory compliance and reimbursement methodologies; and practice establishments and operational consultations.

 

Katie M. Baker, MSHA, CPhT – Manager, Healthcare Consulting

Katie serves as a manager on PYA’s Revenue and Compliance Advisory Services team. Prior to joining PYA, Katie worked as a nationally certified pharmacy technician for more than six years and served as an associate for the Department of Managed Care Contracting at UAB Hospital’s Health Services Foundation. As a manager at PYA, Katie has experience in physician practice operations, revenue cycle and financial controls, physician practice establishment, physician reimbursement, regulatory compliance, and due diligence activities. Katie holds a Bachelor of Science in Management with an emphasis on Healthcare Management and a Minor in Political Science from the University of Alabama. She also holds a Master of Science in Healthcare Administration with an emphasis in Healthcare Finance from the University of Alabama at Birmingham.

 

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Citations:

[1] https://www.ssa.gov/OP_Home/ssact/title18/1834.htm

[2] While CMS waived the state licensure requirement for Medicare, they did not have the authority to waive broader state laws related to licensure.

[3] https://data.cms.gov/sites/default/files/2022-09/Medicare%20Telehealth%20Trends%20Snapshot%2020220906.pdf

[4] Please note that through December 31, 2024, this in-person visit is permitted to be conducted via telehealth.

[5] CMS has also added marriage and family therapists and mental health counselors to the list of eligible telehealth practitioners.

[6] As noted previously, the CAA of 2021 permanently eliminated geographic and location requirements for tele-behavioral health services subject to certain requirements and provided coverage for those services furnished by Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs).