New Ways to Get Paid for Telehealth Services

Betsy Nicoletti, MS


October 14, 2019

Editor's Note:
Betsy Nicoletti, MS, a nationally recognized coding expert, will take your coding questions via email and provide guidance on how to code properly to maximize reimbursement. Have a question about coding? Send it here.

In this column, Nicoletti shares ways to get reimbursed for telehealth, including new codes to use starting next year, plus how to properly bill for telephone services involving a patient.

Getting Private Payers to Reimburse for Telehealth Services

Question: I am in a private family medicine practice and have patients with private insurance (such as Blue Cross Blue Shield, Cigna, and UnitedHealthcare). If I perform an office visit via telehealth, do I use place of service code 02, or add modifiers CG/GT?

Answer: There are specific Medicare rules for telehealth, but let's start with coding and reimbursement for private payers. Each private insurance company determines its own reimbursement policy for telehealth.

The first step is to check with each company to see whether telehealth is a paid service. Then, do use place of service 02 (telehealth) on the claim form, not place of service 11 (office). Also, use Current Procedural Terminology (CPT) modifier 95, synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system. This modifier was added to CPT in 2017. Your staff will need to verify that the insurer recognizes and pays telehealth claims.

Medicare only allows telehealth if the patient is in an underserved area. You can read their policy here.

In 2020, CPT will have three new codes for physicians, nurse practitioners (NPs), and physician assistants (PAs) to use for online digital evaluation and management (E/M) services. These codes, effective January 1, 2020, are defined as "online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days." Use 99421 for a service of 5-10 minutes, 99422 for service of 11-20 minutes, and 99423 for service of 21 or more minutes.

Unfortunately, the proposed fees for these services are low: about $15 for 99421, about $31 for 99422, and about $50 for 99423. Because these are CPT codes and Medicare is assigning them an active status indicator, most payers will recognize and pay them, but they will require patient consent for digital service and tracking, as well as documentation of the time that was spent.

Billing for Telephone Services

Question: I am a pediatric pulmonologist in an academic practice, and we do a significant number of over-the-phone recommendations but aren't billing for these. Can we bill for phone recommendations (for example, starting oral steroids for patients with asthma, starting antibiotics for patients with cystic fibrosis, or discussing CT results)? 

Answer: Physicians, NPs, and PAs in all specialties devote hours of time to activities that are not directly reimbursed. In the case of phone calls, there are few good alternatives.

There are CPT codes for phone calls, but they are assigned noncovered status by Medicare and require patient payment for most insurance companies.

Codes 99441 to 99443 are time-based and are defined as "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." Both the restrictiveness of the definition and the nonpayment status make using these nonstarters for most practices.

There is a Healthcare Common Procedure Coding System (HCPCS) code that can be used for phone calls or other online communications. Currently, it requires specific patient consent before each use and reimburses about $15, nationally. Verbal consent from the patient is sufficient, so offices don't need to secure written consent.

The Centers for Medicare & Medicaid Services (CMS) is currently weighing how frequently consent would be needed: every time, or as part of a general consult. We'll know more when CMS finalizes its 2020 Physician Fee Schedule in November.

Because it is a HCPCS and not a CPT code, not all payers will recognize it. G2012 is defined as "brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, 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." It carries the same restrictions related to a prior E/M service or scheduling and E/M service as the result of the call.

Neither of these are attractive options for paying clinicians for time spent on the phone.

Although payer reimbursement options are limited, your practice can establish a patient-paid fee for phone services or direct inquiries to your patient portal instead. 

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