The answer to this question was a lot clearer on March 1st.
The list of telehealth services was found in two places: CMS’s list of telehealth services and CPT’s list of CPT codes that could be reported via telehealth, in Appendix P of the CPT book. Both CMS and CPT defined telehealth as using a real-time, interactive audio and video communication system. CPT defined modifier 95 as “synchronous telemedicine service rendered via a real-time audio and visual telecommunications system.” CMS and CPT were in agreement.
And, prior to the public health emergency, Medicare only covered telehealth services in medically underserved areas, and required that the patient go to a local medical facility (originating site) to receive telehealth services. Telehealth from home wasn’t covered. That changed with a release of waivers in mid-March, and a new rule published 3/30/2020, making the changes retroactive to early March.
Refer to Telemedicine in the time of COVID-19 FAQ for additional information
Communication-based technology services (CBTS)—not telehealth
CMS began paying for services that used communication technology, but didn’t meet the criteria of telehealth. The patient wasn’t required to be in an underserved area and there was no requirement for real-time audio and visual communication. These included the brief virtual check-in HCPCS codes G2010 and G2012, and on-line digital E/M, 99421—99423. These are not on the telehealth list, are not considered to be telehealth services and do not require modifier 95. The don’t meet the definition of modifier 95, in the first paragraph of this article.
April 30, CMS updates the telehealth list again
The old CMS telehealth list had two columns: code and description.
The March 30 telehealth list had three columns: code, description and a status column with this notation on some rows “Temporary Addition for the PHE for the COVID-19 Pandemic.”
The April 30 telehealth list has five columns: code, description, status and two new columns. One is “Can audio-only interactions meet requirements?” If so, there is a yes on that row. The fifth column is titled “Medicare payment limitations,” and there are a few rows in which the service is noted to be non-covered or bundled.
Services provided by audio-only interactions, that is the telephone!
In the Interim Final Rule with Comment (IFC) published on 4/30/2020, CMS stated it would increase the fees for telephone only services 99441—99443 to match the payment for 99212—99214. They added those codes to the telehealth list, and indicated that “yes” they could be performed via telephone only. That makes sense, since they are telephone calls.
The impact of this for practices is immense. When a patient didn’t have access to a smart phone or computer with a camera, practices were restricted to using the phone codes, which had very low reimbursement. Now, practices can use the phone codes and be paid the same rates as for established patient visits. 99201—99215 still require real time, audio and visual communication.
This is enormously helpful for established patients. For new patients, a clinician can use the telephone call codes, but the new reimbursement rate for phone only follows 99212—99214. If it is possible to use audio/visual communication for new patients, the reimbursement is higher.
New patients, established patients and level of service
CMS has stated that for office and other outpatient visit codes 99201—99215, a practitioner could select a code based on time or medical decision making. During the time of the public health emergency, no specific level of history or exam is required. That is a help for both new and established patient visits, and is similar to the coming new E/M CPT rules for 2021, for codes 99202—99215.
- Use medical decision making, as currently defined
Or
- Use total time spent, including face-to-face and non-face-to-face time. The visit does not need to be dominated by counseling. CMS had released different time thresholds for these visits in the March 30 rule, but in the April 30 rule, CMS said that we should use CPT typical times. CMS said they heard it was confusing to have two sets of time.
Date of posting is May 4, 2020. If I update the article, I’ll indicate that at the top of the page.
The chart below can be downloaded for quick reference
| Medicare covered telemedicine services | Audio only telemedicine services | Communications-based-technology services | CPT list of telemedicine services | |
| Where do you find them? | CMS updated list 4/30/2020 | CMS updated list 4/30/2020 | Not in a single place: G2010, G2012, 99421–99423 | Appedix P of the CPT book |
| Communication requirements | Real-time interactive, audio and visual | Phone only | Phone, HIPAA compliant portal or messaging system | According the the definition of modifier 95, synchronous communication system |
| Place of service, Medicare | CMS says to use the POS where the service would have been furnished, if face-to-face, not POS 02 | Use the place of service where the service would have taken place | Use the place of service where the service would have taken place | |
| Place of service, commercial insurers | Each payer has its own rules | Each payer has its own rules | Use the place of service where the service would have taken place | |
| Modifier, Medicare | Medicare uses modifier-95 | Codes 99441–99443 are added to the telehealth list, so use modifier 95 | Do not use modifier 95. These are not on the telehealth list, and are not considered to be telehealth services | |
| Modifier, commercial | Most want modifier 95 but each payer has its own rules | Each payer has its own rules | Each payer has its own rules |