CodingIntel

Medical coding resources for physicians and their staff. CodingIntel was founded by consultant and coding expert Betsy Nicoletti.

Telemedicine and COVID-19 FAQ

Updated: March 26, 2020, 11:20 am.

  • Medicare releases its rule, relaxing restrictions on telemedicine during the state of emergency
  • Place of service, and CPT modifier 95
  • Other national payers, and Medicaid programs–page down for links to other payers and their rules, that I have as of this date

New resources

CMS releases its rule!

https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

March 6, Congress passed a law relaxing geographic restrictions and distant site mandates on Medicare telemedicine, during a government declared state of emergency. Specifically, medical practices may provide telemedicine services to Medicare patients located anywhere, not just in underserved geographic areas. And, the patient can be in their home, not in an “originating” site. CMS also said that they are waiving HIPAA privacy rules, and allowing applications such as FaceTime and Skype to be used. (CMS uses both terms: telemedicine and telehealth).

Medicare telehealth visits are for office, hospital visits and other services allowed via Medicare’s existing policy for telehealth services. This includes the psychiatric diagnostic interview, psychotherapy, and Medicare wellness visits. There is a full list of these in the article on Medicare telehealth. Under the new regulations, to bill office visits and other approved telehealth services:

  • The provider must use an interactive audio and video telecommunication system.
  • HIPAA privacy rules waived: may use FaceTime, Skype, Messenger video chat, Google hang out video
  • May not use applications that are front facing, such as facebook live, twitch or TikTok
  • CMS instructs groups to notify the patient that third party platforms may have privacy risk
  • 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.
  • 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.
  • Submit these claims with place of service 02.
  • For Medicare, modifier 95 is not required
  • RHCs and FQHCs should use modifier GT on claims.
  • This relaxation of rules is in effect during the state of emergency, and isn’t a permanent change, under the law passed March 6.
  • CMS is paying the service using the facility (lower) rate not the non-facility (office rate)

RHCs and FQHCs

I do not believe that RHCs and FQHCs are exempted from this, and may use telemedicine for Medicare patients. However, the CMS documents don’t mention them. Usually, if a service cannot be done by those entities (some care management services, for examples) the service must be reported with a HCPCS code instead of a CPT code, CMS mentions it.

Take a look at this article:

https://www.aledade.com/what-primary-care-practices-should-know-about-covid-19

However, I heard from someone that the National Rural Health Association did not believe that this included RHCs. When there is a definitive answer, I’ll edit this article.

In plain english: yes, you can bill an office visit via interactive video.

Medicare frequently asked questions about telehealth

Virtual check-ins (some payers are 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.

Virtual communication: two new HCPCS codes G2010 and G2012

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.

CPT® codes( 99421–99423) – and payment for – online digital evaluation and management (E/M) services

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.

Interprofessional Internet Consultations

Telehealth place of service and modifier

The place of service for telemedicine is 02.

CPT added modifier 95 to the CPT book in 2017. Medicare does not require it, but some payers will. 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. Some payers do want modifier 95 on telehealth claims.

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. 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.

Other payers: Here is a terrific summary of telemedicine coverage policies

from the Center for Connected Health Policy

UHC Policy

https://www.uhcprovider.com/en/resource-library/news/Novel-Coronavirus-COVID-19.html

  • Discusses diagnosis coding and new test codes
  • Update on March 17, 2020, UHC expands policies for telehealth for Medicare Advantage, Medicaid and commercial insurance
  • Waives originating site requirements for commercial insurance for services provided via a real time audio and video communication
  • Use modifier 95 for services recognized in the CPT book in Appendix P
  • Recognizes place of service 02, but not required

Athem NH

Anthem NH Telemedicine policy

BCBS of RI 

To help increase access to care during this time of heightened concern about coronavirus disease (COVID-19), BCBSRI has made temporary changes to our policies. We have taken the following steps for our members and providers:

  • Reimbursing participating primary care providers who treat patients over the phone
  • Reimbursing participating behavioral health providers who treat patients over the phone
  • Allowing members to fill prescriptions earlier than the standard 30 days

For details and additional information, please log in to the BCBSRI provider portal to read our COVID-19 FAQs.

BCBS of Florida

Download their policy Here

Aetna and telehealth

https://cvshealth.com/newsroom/press-releases/cvs-health-announces-covid-19-resources-aetna-members

  • Waiving co-pays for diagnostic tests
  • Offering $0 co-pays for telehealth services for any reason for 90 days, effective March 6.
  • However, office visits are not included in the list of services
  • Use place of service 02 or modifier -95

https://www.aetna.com/health-care-professionals/provider-education-manuals/covid-faq.html#acc_link_content_section_responsivegrid_copy__responsivegrid_accordion_10

BCBS companies

https://www.bcbs.com/press-releases/blue-cross-and-blue-shield-companies-announce-coverage-of-coronavirus-testing

  • The network of 36 independent BCBSA companies will have the same policy
  • Waive prior-authorization for diagnostic test and covered services if members diagnosed with COVID-19.  This may be useful for CT scans, which are being used for diagnosis.
  • Will cover medically necessary diagnostic test without cost sharing that are consistent with CDC guidance. Care needed once diagnosis is established “will be covered consistent with the standard provisions of the member’s health benefit.” (That is, not waiving all cost sharing for that.)
  • BCBS will “encourage the use of virtual care and will also facilitate member access and use of nurse/provider hotlines.”  That doesn’t look to me like “we’ll cover telehealth.”

CIGNA

Cigna update 3/17/20

CignaTelehealthPolicy

  • From their release, “To mitigate exposure risks, customers are reminded that telehealth options are available for seeking on-demand medical attention, as appropriate. To access telehealth options, visit mycigna.com and select the “Connect Now” button on the home page to talk with a doctor or nurse any time day or night.”
  • That is, telehealth with their doctor, not the patient’s doctor.
  • Cigna did say they would pay for G2012 and 99241 via telehealth.  See the link above.
  • They have another policy (you can download) that shows an effective date of 6/15/2020.

Humana

https://www.humana.com/coronavirus/covid19-humana-member-resources

  • Testing for COVID-19 is fully covered, no out of pocket expense for the member.
  • Telemedicine visits for all urgent care needs are covered. Waiving out of pocket costs, but no information for providers about how to bill.  This page is intended for consumers.

State of Massachusetts issues an order requiring insurers to cover telehealth, on 3/15/2020

Governor Baker issued the order at 6:50 pm on March 15. (link at the end of the paragraph). “To protect the Public’s health and to mitigate exposure to and the spread of COVID-19, the Group Insurance Commission (“GIC”), all Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts, Inc, and Health Maintenance Organizations (Carriers) regulated by the Division of Insurance (“Division”), are herby required to allow all in-network providers to deliver clinically appropriate, medically necessary covered services to members via telehealth.”

The Massachusetts order goes on to say

  • GIC and all Carriers may establish reasonable requirements for telehealth, including and with respect to documentation and record keeping but these may not be more restrictive that those established by the MassHealth Program, Bulletin 289
  • The GIC and all Carriers shall ensure that rates of payment for in-network services delivered vie telehealth are not lower than in person methods
  • The GIC and all Carriers shall notify providers of any instructions to facilitate billing for these services
  • The GIC and all Carriers are required to cover without cost sharing treatment related to COVID-19 at in-network providers
  • The GIC and all Carries shall not impose prior authorization requirements on medical necessary  treatment delivered via telehealth related to COVID-19 at in network providers

My take away from this:

  • Expect guidance from insurance carriers about how to bill (place of service, whether or not to use modifier 95) and if phone alone is sufficient
  • In the absence of that guidance, I suggest using place of service 02 (telehealth) and modifier 95 (telehealth) but notice that BCBS of NC, which has a policy, distinguishes between phone and services with video and audio.

Check back! I’ll update as more information is provided.

Here’s the link to the state of Mass. https://www.mass.gov/doc/march-15-2020-telehealth-order/download

And, if you get guidance from your carrier or from another state, please email it to me at info@codingintel.org and I’ll update this page.

I’ll also update this page as soon as CMS clarifies how it wants telemedicine to be billed, now that it is updating its policies. (early this week, the week of 3/16)

What about diagnosis coding?

I wrote an article about this for Medscape that you can read here. And, you can read the CDC recommendations for yourself.

Beginning April 1, there is a new ICD-10 code U07.1, 2019-nCoV acute respiratory disease.

I also heard on the news that insurances wouldn’t charge patients a co-pay for treating this illness. Is that true?

Not to my knowledge. There is no federal law currently that mandates coverage for treatment of COVID-19. Some states are discussing this, so you’ll need to check in your own state. The state of Massachusetts 3/15/2020 decree requires insurance companies to cover the care without cost-sharing. This is going to be on a state by state basis, and will change in the days ahead.

AHIP (America’s Health Insurance Plans) published an article about testing for COVID-19, on an insurance by insurance basis, that you can read here.

Check back for updates.

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Comments

  1. To help increase access to care during this time of heightened concern about coronavirus disease (COVID-19), BCBSRI has made temporary changes to our policies. We have taken the following steps for our members and providers:
    • Reimbursing participating primary care providers who treat patients over the phone
    • Reimbursing participating behavioral health providers who treat patients over the phone
    • Allowing members to fill prescriptions earlier than the standard 30 days
    For details and additional information, please log in to the BCBSRI provider portal to read our COVID-19 FAQs.

    • Medicaid is run by the states, and each Medicaid program, can make its own decisions. As I read the law that Congress passed last week (and I’m not a lawyer, so I could be misreading it) it will cover Medicare and Medicare’s telehealth rules.

      CMS is going to issue guidance, early this week, so I would think we’ll know more by Wednesday. I’ll update the article when we do know.

  4. Hello ,Betsy Nicoletti
    Please advise
    Would there be coverage for Physical/occupational therapy provided via telemedia/telehealth? IT is a burning question because the mobility and progress of physical therapy can be lost if patient is not treated – specifically elderly patient
    Thank You

    • This seems unlikely to me. The type of services approved for telehealth are E/M services, psychotherapy, some evaluations. I don’t think PT/OT will be able to be provided via telehealth.

      As of now, still waiting for Medicare to release its guidance, based on the law passed last week. But, PT/OT are not on the current Medicare covered telehealth list. As I read it, the law didn’t expand the list of covered services, but is relaxing geographic and location restrictions.

  5. In regards to Corona Virus outbreak; Are the proper Virtual Medicine Visit codes for telephone office visit:99441-99443? and are they based solely on time spent talking to the patient or on chronic conditions? Does this need any modifiers to bill patient.

    What about codes 99421-99423; will these work for telephone interaction or are these on an online platform only?

    What about codes 99201-99205, and 99211-99215 with POS 02 and GQ modifier? Our biller is directing our office to use these last codes, but does not make sense to me. Please provide direction.

  6. So do we use codes 99213-99214 with modifier codes 95 and POS 02?
    If so can this be over telephone or do we need to use Skype or other platform?

    • There is an article on CodingIntel for those on-line digital E/M codes. They aren’t really “telehealth.” Search for those codes in the search box for the article.

  8. We are being asked if the telehealth reference to well visits means the Medicare annual well visit? Since the AWV requires at a minimum height, weight, BMI (easy once you have height and weight) and blood pressure as well as any other assessments the provider deems appropriate based on medical/family history – can this be interpreted to mean that patient self reported height, weight and BP would be accepted by CMS?
    Thanks

    • This is a puzzle to me, as well. The Welcome to Medicare visit is not on the list, but the initial and subsequent wellness visits are on the list. Since CMS has them on the list, they must know that they can’t be measured! If your patient can self report height and weight, and measure their own blood pressure, I would say that works.

  9. I work in out patient clinic
    There are 2 different data sources of information that are confusing me.

    https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet?fbclid=IwAR2ph0vbivjXhPHQgXtuOzEnH2S_u6CCiQZpy-hbWPdnwJ110aNUZm8OLog

    Also under the fact sheet for Medicare Telehealth released info as of March 17, 2020
    https://edit.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf?fbclid=IwAR2tbC0K25mh8VsBP_P3NhAsFFWfuzT4MVX4e8z3qdtlNbT-fq55YLyVKPE attached to that is https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Downloads/covered-telehealth-services.zip

  10. Carefirst DC and Maryland will allow Primary medicine specialists and OB/GYN docs who are designated Primary medicine doc can use the telemedicine codes. They have their own website for patients to access. I’ve researched everything and can find nothing where they are relaxing their rules to allow any physician to bill telemedicine 992xx – 99215. If I find anything, I’ll repost

  11. What is your opinion on the use of Prolonged Non Face-to-Face E&M (99358/99359) in lieu of TeleHealth? We have a huge population of elderly patients who do not have video capability for TeleHealth services. Do you think we could utilize 99358/99359 for an E&M via telephone. Per NGS, includes usage of telephone.

    Per NGS: “The codes may be used to represent extensive telephone time (31 or more minutes) with the patient and/or a responsible family member. Again, the telephone time must be linked to a face-to-face encounter which may occur either prior or subsequent to the telephone discussion. ”

    https://www.ngsmedicare.com/ngs/myportal/ngsmedicare/newngs/home-lob/pages/policy-education/evaluation%20and%20management/prolonged%20services%20non-face-to-face/!ut/p/z1/rVNdb4IwFP0t-wGkt7RCeSwFoeBAp-joi8EBC5lfMU6zf79qjFtmRJetL03Tc86999x7kULPSC2LXfNabJvVspjrd66sKeXSx1hAnLIQgMcepzwJSEAJmvwAkJQBp13X8wZ9ErgmUt-_mSQWcNElsUlc3JH2iQ9XDof7-JiFIpQMekE8JMAt4bNu0CMA9n38KwWmQ_gl_xKg2v0bo1ygfDyvmoi3J3NAq3avJkgdIWc7IHWptqODh3YcAYjOCfAVQvhc98tLrIR3cQqXgMuG3spCtdV8sDTXZdpTy3mUgcPMhGUDBgMZ-U5f5wgpoOFBo1ms581Ls31cldUc5dvNe3ViXjNIaAd2TbVH2XK1WejpPeqsX5oS5bTEM1w6jlHWMDOoXWHDIbQyZjUprLqgVskwCuFWBPOPEW7I4_-Vhw7WzRNU2jQMzXRk_698kElfZ-_GWS8DUwb0j_LRrWWZeOdVUfi4La1jtF5kh7P8MN6e_DpJjDza7fejeiFm7HR9TCV_-AR7Fj-S/dz/d5/L3dHQSEvUUtRZy9nQSEh/#Code%20Definition

    Much appreciated!! 😊

    • I’ve seen that from NGS and I personally disagree with it. There are telephone codes in the CPT book that describe phone calls. I don’t think you can elect to use a code that is payable in place of one that doesn’t pay (phone calls with CPT codes). I think the principle of selecting the most accurate CPT code that describes the service leads you to the phone codes. That don’t pay. Having said that, it is on NGS’s website. I wouldn’t do it for any other MAC, of course.

  12. During this Covid emergency can the telehealth codes and E&M codes be used by specialist drs like Pain, Ortho GI, to do their follow-up visits via facetime etc or is this only for Pimary care type of providers. Appreciate all you do.

  13. Question for you:
    How about if due to COVID, the provider is quarantined to work from home? They can use the telehealth codes, right? Provider at home performing the service via skype and patient at home receiving the service via skype. That is okay, right?
    Another question with the timed codes, such as G0425 (30), G0426 (50), G0427 (70). Is there a time threshold to meet? G0425 and G0427 have same key requirements with exception of the time. If you make the requirements of PF HX and PF EX and SF MDM, but timed at 35 minutes, could you still bill G0426.
    Last question: Are ED providers locked into the G codes or can they use the 99201-99205 for the telehealth?
    Thank you.

    • Yes. CMS released guidance yesterday (on Sunday) about changing the provider address to the home address. I don’t know what to do if sometimes home/sometimes at the office.

    • If the provider is always working from home, you need to call Medicare and update location of practice address. See the CMS enrollment notice at the top of the article.
      Yes, if the code is a timed code, you must meet the threshold to bill it. If you don’t have a HCPCS book, you can look these up on http://www.hipaaspace.com. Those codes are defined by time.
      I don’t know of any restrictions on type of providers and use of new patient visit codes.

  14. Need clarification, if the patient is scheduled for a normal follow-up (99212 – 99215) by a specialist for his ongoing treatment, can the provider tell the patient that we are offering the televisit as an option, instead of coming to the office. Does that count or does the patient have to initiate the visit.

    • That counts. There is no requirement that the patient “initiate” an office visit billed via telehealth. The rule about “patient initiated” service relates to the on-line digital codes, 99421–99243.

    • Yes. The patient does not need to “initiate” telehealth billed with new/established office visit codes. The patient needed to initiate the on-line digital E/M services (those codes didn’t require any face to face video) 99421–99423.

  15. Submitted 3/23/2020 by a reader:

    Although I am not a member, I want to make sure that I am reading Cigna’s policy correctly. They (unlike almost all other insurance companies) are not allowing physicians to continue operations using the regular E&M codes until 6/15/20 and then they will only reimburse at 50% of the allowed amount. Other than treatment for Covid-19, they are only allowing 99241 and G2012. In my opinion, it is a disgrace and they need to be called out for being one of the only major insurance companies penalizing doctors and their patients by not paying for regular care during this emergency.

    • I completely understand your question. When I saw Cigna’s policy, I sent it to a few fellow consultants and said, “Am I reading this right?” The Cigna policy, “updated March 17, 2020” does not allow for office visits via telehealth. They will pay for 99241 and G2012. Both, low paying services that do not represent the typical work of an office visit.

      I can only hope and believe that they will update their policy before long.

  16. Need some help. Can a NPP bill incident-to if the telehealth service is done in the office under the direct supervision of a physician? There is some confusion as Telehealth services are billed with POS 02 and Incident-to is usually only for POS 11. The NPP and physician are in the office even though the patient is home. Some believe that Incident To should be approved because CMS states “within their scope of practice and consistent with Medicare benefit rules that apply to all services”.

    • The telehealth rules did not change incident to rules. If the physician is in the same suite of offices with the NPP, it would seem incident to is okay. I don’t have a citation. The physician must be immediately available to the NPP. If the physician and NPP are working remotely from one another, no.

      My suggestion: bill the NPP services under their own NPI.

  17. Betsy, Can you confirm the lab test for COVID19 the U0001 or the 80000 code should not be billed if the physician office is collecting the specimen unless they have high complexity testing ? I think our challenge is our hospital lab is capturing it and that translated over to our MD practices…”In guidance that immediately took effect late last week, the FDA explained that the policy will only apply to laboratories that are certified to perform high-complexity testing consistent with requirements under the Clinical Laboratory Improvement Amendments, which regulate laboratory testing and require clinical laboratories to be certified by CMS before they can accept human samples for diagnostic testing”.

    • If you are obtaining the sample, you do not bill either the HCPCS code for the test or the CPT code for the test. The lab that does the test bills those codes. All you can bill is 99000 which is typically non-covered.

  19. Our question was: If the patient does not have access to video/audio capabilities and/or denies the video aspect of the telehealth visit, will Medicare pay for the service?

    Answer:
    A phone only visit is appropriate if you know enough about the patient to provide services by phone and able to treat by phone. I would document that it is a telemedicine visit but the patient declined video or does not have video capabilities. Bill CPT codes you would use with the patient in person with a 02 place of service code.
    Becky Bounds, MSN, RN-BC, CPHQ
    TexLa Telehealth Resource Center
    806.743.9834

    • I don’t agree with this for Medicare patients. CMS is requiring real-time audio/video with the patient. Without that, the only paid code you can use for a phone call is Q2012.

  21. I noticed there are subsequent codes in the inpatient world (99231-99233). How about if a hospitalist needs to admit or discharge the patient via telehealth? What codes would they use? This would be different than the consultations (i.e. G codes). Thank you.

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Our mission is to provide accurate, comprehensive, up-to-date coding information, allowing medical practices to increase revenue, decrease coding denials and reduce compliance risk. That's what coding knowledge can do.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions. For more about Betsy visit www.betsynicoletti.com.

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