During the public health emergency (PHE), CMS and private payers relaxed the restrictions on telehealth. These changes are intended to be temporary. In the 2021 CMS Final Rule, CMS indicated that they do not believe they have the statutory to continue with the waived restrictions after the end of the PHE. When the PHE ends, CMS no longer is planning on allowing office visits in all areas, when the patient is at home, and is not planning on continuing to pay for telephone codes 99441–99444. Perhaps CMS will change its mind, but this is what was indicated in both the 2021 and 2022 Final Rules.
There are links in this article to other resources on CodingIntel. But, payer policies aside, the CPT book includes a modifier for telehealth services, a symbol to indicate that from their perspective the code that describes the service may be done via telehealth, and an appendix with a list of these CPT codes. CMS and individual payers have their own lists.
An Overview of Telemedicine Modifier -95:
- Read the telemedicine article for the most up-to-date information during the public health emergency!
- Also, see the article published April 13, 2020 on the new CS modifier
The American Medical Association added this modifier and symbol in 2017, along with and Appendix P to CPT®
In the CPT book, there is a star next to codes that CPT believes can be reported via telemedicine, and these are listed in Appendix P. Of course, government payers and commercial insurers have their own coverage rules.
Modifier -95 Synchronous Telemedicine Service Rendered via Real-Time Interactive Audio and Video Telecommunications System.
Synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified healthcare professional and a patient who is located at a distant site from the physician or other qualified healthcare professional.
The totality of the communication of information exchanged between the physician or other qualified healthcare 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 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. The codes that the AMA defines as telemedicine codes are also listed with a star in the tabular listing. Of course, the CPT book does not reflect CMS waivers and payer policy changes during the public health emergency.
Modifier -93 Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive Audio-Only 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 away 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 is sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction.
- The AMA intends this modifier for when there isn’t real time, audio/visual communication, but a phone only encounter.
- They say that the service “must be of an amount and nature that is sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction.” That is, does the encounter support an office visit or hospital visit? The December 2021 CPT Assistant doesn’t include any information about modifier -93.
- As far as I can see, CMS has not addressed the use of this new modifier. We will have to watch our payers’ newsletters to see if they are adopting it.
Other telehealth modifiers:
For use in Alaska and Hawaii for demonstration projects: GQ
For use by CAH method II hospitals: GT
Services furnished for purposes of diagnosis and treatment of an acute stroke: GO
New, 3/7/2020 modifier CS
CMS MLN Matters article on 3/7/20 stated that from March 18 until the end of the public health emergency, there will be no patient due amounts for services related to COVID-19 testing. These can be re-submitted with modifier CS. It includes both the testing and the visits related to the testing. Here is what CMS said in their MLN article.
In addition, there is a new symbol to indicate that a CPT® code may be reported via telemedicine and the new appendix that lists CPT® codes that may be used for synchronous telemedicine services. Missing from the list in Appendix P are HCPCS codes that may be reported via telehealth.
If reporting a service via telehealth that is related to COVID-19, append both modifier CS and modifier 95, in that order. CMS has not said that, but in general, I recommend using the modifier that affects payment (CS) first, and the informational modifier (95) second.
The information below is about telehealth before the public health emergency. It may be accurate again after the emergency is over, but in the meantime, look at the telehealth article on the site.
I’ve written before about telehealth, and that telehealth is not skype with your doctor. You can read that here. You can download CMS’s fact sheet about telehealth:
There are also some insurance companies that offer telehealth services to their subscribers, not with the subscriber’s own physician but with someone contracted with the insurance company. This is similar to a “call a nurse” function that some insurance companies have. But, neither of those are the subject of this article.
Telehealth is a benefit for fee-for-service Medicare beneficiaries in a Health Professional Shortage Area (HPSA) either outside of a Metropolitan Statistical Area (MSA) or in a rural census tract or a county outside of a MSA who need a professional service from a healthcare professional in another location, and the service is provided via telecommunication.
Anyone can suggest a service to Medicare for coverage via telehealth, and CMS considers these and publishes a list of new telehealth services each year in the Physician Fee Schedule Final Rule.
These include both CPT® services and HCPCS services. CMS will develop HCPCS codes when the service described either doesn’t have a CPT® code or when CMS wants to distinguish it in some way from a CPT® code.
There are many HCPCS codes that may be reported via telehealth for Medicare patients, and these are not included in the CPT® book appendix. They are in the CMS fact sheet. (link above)
Key Points of Telemedicine Modifier 95 when not in a public health emergency:
- CMS pays for telehealth services for fee-for-service Medicare patients who live in a healthcare shortage area
- Synchronous, real-time communication is required
- The originating site is paid a small fee
- The performing/consulting site bills a CPT® or HCPCS code, with a modifier
- CPT® has new telemedicine modifier, modifier -95, a new star symbol for telehealth services and an appendix that lists only CPT® codes eligible for telehealth, not the additional Medicare covered HCPCS codes
- Each year, CMS updates their fact sheet on telehealth to add in newly covered services
There are articles on CodingIntel that describe two HCPCS codes, G2010 and G2012, for non-face-to-face remote services, and beginning in 2020, codes for on-line digital E/M services, 99421-99423. None of these codes are for remote, real time E/M services with a patient.