Updated (again) May 17, 2023. Will there be more changes? CMS says going forward policy changes will be through its existing rule making mechanism, the proposed rule released at the end of June and the final rule released at the end of October.

Coding for telehealth is everchanging. This article describes what will happen after the PHE ends 5/11/2023
Some of these changes were described in the 2023 Physician Fee Schedule. Some are flexibilities that CMS enacted. And some were mandated in the Consolidated Appropriations Act of 2023, by Congress.
CMS continues to pay for office visits via audio/visual communications (99202–99215) and office visits via audio only communication (99441–99443) during the pandemic. CMS will pay for audio only telehealth until Dec. 31, 2024 at the same rate as office visits using codes 99441-99443.
Congress passed a law in 2020 mandating that after the PHE ends, behavioral health services will continue to be allowed via telehealth, audio/visual and audio only.

2023 updates:

The AMA has developed a new modifier, -93 for audio only services. Medicare is requiring its use in 2023. There is a new speaker symbol in the 2023 CPT book for services that CPT states can be performed via audio only, and these are listed in Appendix T.
Starting 1/1/23, FQHCs and RHCs should use modifier 93 for audio-only visits, replacing modifier FQ.
The Consolidated Appropriation Act of 2023 extended some telehealth flexibilities until 12/31/24 (details below)
Reimbursement for Q3014, originating site payment, will be $28.61.
Place of service: read this article on CodingIntel. https://codingintel.com/coding-telehealth-visits/
The PHE is set to expire May 11, 2023

Coding for telehealth for Medicare after the PHE ends 5/11/23

Question: What telehealth flexibilities expire on 5/11/23?

Answer:

Practitioners will need to report their home address for telehealth services after 12/31/23, not 5/11/23. After 12/31/23, if a practitioner is performing telehealth at home, they will be required to report their home address on the Medicare enrollment site. That’s bad news.
Telehealth platforms must be HIPAA compliant after August 19, 2023.
Cost sharing requirements will be enforced. During the PHE, practices were not required to collect the co-insurance/deductible although most did.
The DEA will require prescribers to see a patient face-to-face before administering controlled substances.
Supervision of services requiring direct supervision may not be performed virtually after Dec. 31, 2023. Services (think incident to services or diagnostic tests that required direct supervision) must be supervised by a physician or NPP who is physically in the suite of offices after Dec. 31, 2023. These will no longer be able to be supervised virtuallyl.
CMS is allowing virtual supervision of residents until Dec. 31, 2023 and states they will consider this further in their rulemaking process.
For the teaching sites that practice under the primary care exception, levels 4 and 5 E/M services may not be provided by a resident alone.
Patients will be required to pay coinsurance for interprofessional consults and beneficiary consent will be required.
Remote patient monitoring may be furnished only for established patients.
Virtual check in codes will only be allowed for established patients
Federally mandated nursing facility visits will need to be done in person.
Frequency limits:
1. Prior to the PHE, there was a frequency limit of every three days on subsequent hospital visits furnished via telehealth. This is re-instated.
2. Subsequent nursing facility visits may only be done via telehealth once every 14 days.
3. Critical care codes G0508-G0509 have a frequency limit of once/day

Question: What is happening to telehealth after the Public Health Emergency expires on May 11, 2023?

Answer: The Consolidated Appropriates Act of 2023 passed by Congress in Dec. 2022 extended some Medicare telehealth provisions until Dec. 31, 2024. Some, but not all of the flexibilities medical practices are used to having. The law does not require commercial insurances to follow these rules. But for Medicare:

Medicare patients will continue to be able to receive telehealth in their homes, regardless of geographic location
Medicare patients can continue to receive audio-only telehealth visits from practitioners
For behavioral health audio-only visits, Congress delayed the implementation pre-requisite of an in-person visit
FQHCs and RHCs can be distant site providers of telehealth
The expanded list of practitioners continues and includes physical and occupational therapists, speech language pathologists, and audiologists

What about payment parity? Medicare has told practitioners to use the place of service (POS) that would have been used if the patient was seen in person rather than POS 02 telehealth. If the patient would have been seen in the office, (POS 11) that results in a higher non-facility payment. If POS 02 is used, it results in a lower payment, at the facility rate. The 2023 Physician Fee Schedule instructed practitioners to continue to use the POS that would have been used if the patient was seen in person. That ends Dec. 31, 2023.

There are now two telehealth POS codes but don’t start using them.

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

POS 10: Telehealth Provided in Patient’s Home

Don’t use POS 02 or 10 if you would have used POS 11 for the office service. This is important! Using POS 02 or 10 for Medicare patients will result in lower reimbursement in 2023, thereby foregoing the payment parity CMS is allowing! Don’t believe me?

Read it for yourself in this MedLearn matters article.

https://www.cms.gov/files/document/mm12427-newmodifications-place-service-pos-codes-telehealth.pdf

Flexibilities that are extended until Dec. 31, 2024

Patients can receive telehealth services in their homes in any geographic location
In addition to physicians and non-physician practitioners, physical therapists, occupational therapists and speech language pathologists can provide telehealth services
Audio only services may be performed, reported with codes 99441–99443
FQHCs and RHCs can perform telehealth services

Resources to download regarding telehealth

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Medicare telehealth policies during the public health emergency

Telephone codes were added to the list of services that can be billed via telehealth, and the rates for codes 99441–99443 were increased, to match the rates for 99212–99214
Office visit codes must still use two-way audio and visual, real time interactive technologies, but the payment rates for audio only codes (99441–99443) were increased
CMS added to the list of services that can be provided via telehealth to include additional hospital services, home visits, and domiciliary services, inpatient neonatal and pediatric critical care and intensive care codes may be performed via telehealth
Additional services that are temporary additions to the services that may be performed via telehealth include care planning for patients with cognitive impairment, psychological and neuropsychological testing, physical therapy and occupational therapy and occupational therapy. The blanket waivers were updated at the end of April and physical therapists, occupational therapists and speech-language pathologists are now on the list of clinicians who can bill telehealth
Subsequent inpatient telehealth may be performed daily, without the prior limit of once every three days
See the full list here.
The list of telehealth services include some that may be reported using audio equipment only
In order to bill office visits or any of the services that are not indicated as video only, on the list above, you must have interactive, real-time audio visual with the patient.

Telehealth across state lines

In many states, a physician may not treat a patient who is in another state. Check with your board of medical practice or professional society. Or, look here for licensure requirements for telehealth during the pandemic, go here: FSMB (Federation of State Medical Boards): https://www.fsmb.org/

Search by typing in telehealth, it takes you to here: https://www.fsmb.org/search-results/?q=telehealth

Click on: States waiving licensure requirements in Response to COVID-19

This document has been updated monthly during the state of emergency. The “notes section” of each state will either summarize the rule for treating out of state patients via telehealth or will provide a link to the policy.

Here is the direct link to the July 2022 publication from their website: https://www.fsmb.org/siteassets/advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in-response-to-covid-19.pdf

Place of service and modifier

In March 2020, CMS released an interim rule with other changes.

For Medicare claims, use the place of service that would have been used if the patient had been seen face-to-face. Do not use POS 02. This means, if it is an office visit, you will be paid the higher, non-facility rate, not the facility rate. This is about $20 difference for office visits billed with POS 11. CMS now says to use modifier 95 on the claim. If billing in an outpatient department, use place of service 19 or 22. Use the place of service that would have been used. Append modifier 95 to the claim.

Medical practices need to check with their private payers to see what POS and modifier they require.

Selecting a level of service

Ue MDM or time to select a level of service.

Not defined as telehealth

On-line digital E/M (99421–99423 and 98970–98972), virtual check in (G2010, G2012) and remote monitoring are not considered telehealth services. Do not use POS 02 or modifier 95 with these.

For Medicare, telephone codes (99441–99443) are now defined as telehealth services, because they are on the CMS telehealth list.

Medicare telehealth visits are for office, hospital visits and other services allowed via Medicare’s existing policy for telehealth services. Under the new regulations, to bill office visits and other approved telehealth services:

The provider must use an interactive, real-time audio and video telecommunication system in order to bill office visit codes 99201–99215. If the patient does not have access to a smart phone or computer, do not bill office visit codes.
HIPAA privacy rules waived. This ends May 11, 2023 when the PHE is over. Then, practices must use a HIPAA compliant platform.
Practitioners who may bill for telehealth include physicians, advanced practice registered nurses, physician assistants, CRNAs, clinical psychologists, clinical social workers, registered dietitians and nutrition professionals. The rule released on 3/30/2020 adds therapy codes to the list, and the April 30 rule added physical therapists, occupational therapists, and speech-language pathologists.
Visits are paid at the same rate as in person visits.
The provider may waive the co-pay/deductible but is not required to do so.
Virtual communication (phone calls, virtual check in codes G2010 and G2012, and digital E/M are not considered telehealth. Information about those services is below. Do not use place of service 02 for those services. These are not considered to be telehealth services.
Remote monitoring services are covered, as well, are also not considered telehealth and do not require place of service 02.

On-site visits via video or through a window–report as telehealth?

CMS’s FAQ from 4/9/20 said that if the physician/NPP and the patient are located in the same facility, but not in the same room, and are communicating via telecommunication, these do not need to be reported as telehealth. Use the codes that describe the in person communication. (COVID-19 Interim Final Rule FAQs)

Supervision

CMS said in their 3/30/20 rule that direct supervision could be provided via audio/visual, real time communication.

RHCs and FQHCs

The CARES Act opened up payment for E/M services in these locations. Use code G2025.

RHCs and FQHCs may bill G0071, payment for communication technology-based services for 5 minutes or more of a virtual (non-face-to-face) communication between an RHC or FQHC practitioner and RHC or FQHC patient, or 5 minutes or more of remote evaluation of recorded video and/or image by an RHC or FQHC practitioner, occurring in lieu of an office visit; (RHC or FQHC only). The updated rate is $24.76.

CMS finally released instructions about FQHC and RHC billing. There is a link to the MedLearn matters document at the article.

https://codingintel.com/telemedicine-in-rhcs-and-fqhcs/

Payment for phone calls

CMS will pay for phone calls using codes 99441—99443, and 98966—98968
CMS stated in their 3/30/2020 rule that these codes may be used for new and established patient visits during the public health emergency
Physicians, nurse practitioners, and physician assistants should use codes 99441—99443
Other qualified health care professionals who may bill Medicare for their services, such as registered dieticians, social workers, speech language pathologists and physical and occupational therapists should use codes 98966—98968

Real-time audio visual equipment is not required for G2012, G2010 or 99421—99423 because those are not considered telehealth services. The requirements for those are described in the article on telehealth, and in separate entries on CodingIntel.com. Links are listed later in this article.

Per the CPT definition, phone call codes 99441—99443 and 98966—98968 are services initiated by the patient (CMS did not discuss if this requirement was waived or not). They may not be provided if they are in follow-up for a visit within the past 7 days, or if they result in a visit in the next 24 hours, or next available appointment. While 99441–99443 were added to the telehealth list and the rates increased, the same is not true for 98966–98968.

Physicians, nurse practitioners, clinical nurse specialists, certified nurse midwives and physician assistants use these codes:

99441 Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent or guardian 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

99442 11-20 minutes of medical discussion

99443 21-30 minutes of medical discussion

Registered dieticians, social workers, speech language pathologists and physical and occupational therapists use these codes

98966 Telephone evaluation and management service by a qualified nonphysician health care professional to an established patient, parent or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an evaluation and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

98967 11-20 minutes of medical discussion

98968 21-30 minutes of medical discussion

Resources

Virtual check-ins (some payers use these, not office visits)

CMS is still paying for their HCPCS codes G2012 and G2010. You know what I think about these codes. Too little money for the effort to do and document. But, these don’t require real time audio/video, the way office visits do. CMS stated in their 3/30/2020 rule that G2012 may be billed for both new and established patients during the public health emergency period.

On-line digital E/M (some payers paying these, not office visits)

CMS began paying for these in 2020. These aren’t office visits via audio/video, but are more complex and convoluted to do and document. But, they were mentioned in CMS’s rules, and so I’m including them.

Interprofessional consults (may be useful in the hospital setting)

These are not officially part of telehealth, but some groups are using them now in the hospital, so that fewer physicians see each patient in the hospital. They allow a consultant to do a time-based chart review and provide a verbal and written report back to the requesting clinician without seeing the patient.

Telehealth place of service and modifier for Commercial Payers

The place of service for telemedicine is 02.

CPT ^® added modifier 95 to the CPT book in 2017. Medicare now requires it for telehealth, and many commercial payers do, as well. Experienced coders, billers, and administrators know that it is too much to hope that all of the payers will want claims to be submitted in the same way.

Modifier -95 Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System: Synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional.

The totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction.

Modifier 95 may only be appended to the services listed in Appendix P in the CPT book or on the list of CMS telehealth services, referenced at the start of this article. Appendix P is the list of CPT codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system.

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